Guideline
Ministry of Health, NSW73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
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NSW Rural Paediatric Emergency Clinical Guidelines SecondEdition
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Document Number GL2014_007
Publication date 26-May-2014
Functional Sub group Clinical/ Patient Services - Baby and childClinical/ Patient Services - Medical Treatment
Summary Emergency Clinical Practice Guidelines to be used by PaediatricAdvanced Clinical Nurses for initial treatment of infants and childrenpresenting to emergency departments in rural areas. This Guideline,GL2014_007 replaces PD2011_047.
Author Branch NSW Kids and Families
Branch contact NSW Kids and Families 02 9391 9777
Applies to Local Health Districts, Chief Executive Governed Statutory HealthCorporations, Specialty Network Governed Statutory HealthCorporations, Affiliated Health Organisations, Public Hospitals
Audience Emergency Departments, Paediatric Units, Nursing
Distributed to Public Health System, Divisions of General Practice, NSW AmbulanceService, Ministry of Health, Private Hospitals and Day Procedure Centres,Tertiary Education Institutes
Review date 26-May-2017
Policy Manual Patient Matters
File No. H14/31240
Status Active
Director-General
GUIDELINE SUMMARY
NSW RURAL PAEDIATRIC EMERGENCY CLINICAL GUIDELINES
PURPOSE These Clinical Guidelines provide a clear standard of initial care for children who present to Emergency Departments where Medical Officers are not immediately available. It is intended that the Clinical Guidelines will be used by Paediatric Advanced Clinical Nurses to facilitate the early and appropriate clinical management of children who present to Emergency Departments with acute and life threatening conditions and to relieve pain and discomfort. This is the second edition of the document which has been developed in line with current best practice and advice from expert reviewers. This document is a companion document to the NSW Rural Adult Emergency Clinical Guidelines.
KEY PRINCIPLES These NSW Rural Paediatric Emergency Clinical Guidelines are underpinned by the following principles: A ‘graduated’ clinical response is required depending on the:
• Severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma
• Level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions. Nursing staff using these clinical guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses
• Legal requirements for nurses who initiate treatment and administer medications based on medication standing orders
• Need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances.
The Clinical Guidelines reflect evidence based best clinical practice and expert consensus opinion, in regards to standardisation of initial clinical management of specific paediatric conditions and alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses. Any medication standing orders contained in these clinical guidelines will have no legal basis unless they are approved by the Local Health District Drug Therapeutic Committee (or local hospital Drug Therapeutic Committee if there is no District Committee), as specified in NSW Health Policy Directive PD2013_043, Medication Handling in NSW Public Health Facilities, (Section 7.4 Standing Orders). Each standing order must be signed and dated by an appropriate senior Medical Officer and by the Chairperson of the Drug Committee that is approving the standing order. The
GL2014_007 Issue date: May-2014 Page 1 of 2
GUIDELINE SUMMARY committee must review the standing order annually and re-endorse and date the standing order to confirm on-going approval.
USE OF THE GUIDELINE These guidelines are to be used for children up to their 16th birthday only and have been formatted to follow the generally accepted Airway, Breathing, Circulation and Disability (ABCD) approach for managing emergency/critically ill patients. Advanced Clinical Nurses have advanced knowledge and skills, have completed an advanced emergency or critical care nursing course or hold a graduate certificate/diploma in paediatric nursing – emergency stream and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines the:
• Designated medical officer will be notified as soon as practicable • Medical Officer will review any patient who has been given medications
consistent with the standing orders contained within this document as soon as possible (must be within 24 hours). At the time of this review the Medical Officer must check and countersign the nurse record of administration on the medication chart.
A number of the incorporated procedures have been adapted from the NSW Health Acute Paediatric Clinical Practice Guidelines. Where applicable and advised, subsequent treatment and management should follow the NSW Health Paediatric Clinical Practice Guidelines.
REVISION HISTORY Version Approved by Amendment notes May 2014 (GL2014_007)
Deputy Secretary Population and Public Health
Second edition. Guidelines updated to align with:
• Parameters of Standard Paediatric Observation Chart (SPOC)
• Paediatric Clinical Practice Guidelines- particularly Recognition of the Sick Baby and Child;
• DETECT Junior; • Paediatric Sepsis Pathway and • Clinical Escalation and Response Systems.
July 2011 (PD2011_047)
Deputy Director-General Strategic Development
New policy- made obsolete.
ATTACHMENTS 1. NSW Rural Paediatric Emergency Clinical Guidelines
GL2014_007 Issue date: May-2014 Page 2 of 2
C HANGE
2nd EditionNSW Rural Paediatric Emergency Clinical
GuidelinesNSW Children’s Healthcare Network
Paediatric Clinical Nurse Consultant Group
2nd Edition
AcknowledgementsThese Guidelines were originally developed by the NSW Child Health Networks
Paediatric Clinical Nurse Consultant Group in consultation with the NSW Rural
Critical Care Task Force, NSW Rural Critical Care CNC Planning Group, the
Clinical Excellence Commission, and Statewide Services Development Branch,
between 2005-2012. There has been significant direction and contribution
by the specialist clinicians in the field. The considerable effort of all involved
is acknowledged. We also acknowledge the valuable contribution of the
critical readers.
NSW MINISTRY OF HEALTH NSW Kids and Families73 Miller StreetNORTH SYDNEY NSW 2060Tel: (02) 9391 9491Fax: (02) 9391 9928TTY: (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in partfor study training purposes subject to the inclusion of an acknowledgementof the source. It may not be reproduced for commercial usage or sale.Reproduction for purposes other than those indicated above, requires written permission from the NSW Ministry of Health.
This Clinical Practice Guideline is extracted from the GL2014_007 and as a result, this booklet may be varied, withdrawn or replaced at any time.
©NSW Ministry of Health 2014
SHPN (NKF) 140138ISBN 978-1-74187-000-8
Further copies of this report can be downloaded from the:NSW Health website: www.health.nsw.gov.au
Content within this publication was accurate at the time of publication.
May 2014
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE i
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
The NSW Rural Paediatric Emergency Clinical Guidelines
are to be implemented for the emergency management
of paediatric patients only.
A child is defined as up to their 16th birthday.
NSW Health PD2010_033 Children and Adolescents – Safety and Security in NSW Health Acute Facilities
Newborn and paediatric Emergency Transport Service
(NETS) 1300 36 2500
The NSW Rural Paediatric Emergency Clinical Guidelines are aligned with the Standard Paediatric Observation Charts, Clinical Emergency Response System, NSW Acute Paediatric
Clinical Practice Guidelines, DETECT Junior and the Paediatric Sepsis Pathway.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE ii
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
PAGE ii
Introduction ........................................................ 1
Abbreviations ...................................................... 4
Definitions ........................................................... 5
1. Assessing Children ........................................ 7
2. Recognition of A Sick Child ........................ 17
3. Airway Emergencies .................................... 21Anaphylactic Reaction ........................................... 21Croup ....................................................................25Foreign Body ......................................................... 28Seizures ................................................................. 30Unconscious Patient .............................................. 33
4. Breathing Emergencies ............................... 37Asthma ................................................................. 37Bronchiolitis ........................................................... 42
5. Circulatory Emergencies ............................. 45Paediatric Basic Life Support .................................. 45Paediatric Cardiac Arrest........................................ 46Gastroenteritis ....................................................... 48Shock .................................................................... 52
6. Disabilities .................................................... 55Suspected Bacterial Meningitis .............................. 55
7. Envenomation/Poisoning Emergencies ..... 59Poisoning .............................................................. 59Snake/Spider Bite .................................................. 63
8. Trauma Emergencies ................................... 67Severe Burns ......................................................... 67Drowning .............................................................. 73Head Injury ............................................................ 77
9. Other Emergencies ...................................... 82Abdominal Pain ..................................................... 82Febrile Neutropenia ............................................... 86
Formulary .......................................................... 88
Appendices ..................................................... 118Appendix 1: Rural and Remote Emergency
Trolley – Minimum Paediatric Requirements ................................. 118
Appendix 2: Additional Recommended Paediatric Equipment ..................... 120
Appendix 3: Paediatric Respiratory Assessment and Oxygen Therapy ... 122
Appendix 4: AVPU and The Modified Paediatric Glasgow Coma Scale ..... 123
Appendix 5: Primary and Secondary Survey .......124Appendix 6: Snakebite Observation Chart .........125Appendix 7: Paediatric Pain Assessment ............126Appendix 8: Burn Injury Referral/Retrieval Check List ..................................... 128 Appendix 9: Head Injury Risk Categories .......... 132Appendix 10: Guideline for Emergency Department Documentation ......... 135Appendix 11: Sedation Score .............................. 137
Contents
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 1
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
1
Emergency Departments (EDs) in rural and remote
New South Wales (NSW) face a number of unique and
difficult challenges in trying to deliver quality paediatric
emergency care. In particular it can be difficult for staff
working in rural and remote EDs to acquire and retain
emergency expertise related to paediatric presentations.
This may lead to inequities in the standards of
emergency care delivered in rural and remote EDs.
A key function of the NSW Children’s Healthcare
Network Paediatric Clinical Nurse Consultant Group is
to identify and develop ways to ensure a more uniform
approach to the delivery of paediatric emergency care in
rural and remote EDs. One of the group’s strategies led
to the development in 2010 of a set of rural emergency
clinical paediatric guidelines which could be used by
rural and remote Registered Nurses (RNs) who have
undergone approved education, skills and credentialing.
The intention of these Guidelines is to ensure the early
management of children who present to emergency
departments where Medical Officers are not immediately
available. The guidelines include management of
immediately or imminently life-threatening conditions.
The Guidelines provide a clear standard of care for
paediatric emergencies in an attempt to ensure good
patient outcomes are achieved.
This is the second edition of the document and has
been developed in line with current best practice;
and requests and advice from expert reviewers. These
Guidelines are a companion document to the NSW Rural
Adult Emergency Clinical Guidelines, and so, the format,
clinical assessment, interventions and many of the
appendices for these Guidelines have been taken from
the 3rd Edition of the Adult Guidelines. The document,
like the Adult Guidelines, has been developed with the
following desirable features:
n formatting which allows for ‘graduated’ clinical
responses. These responses vary depending on the:
– degree of severity of the presenting paediatric
emergency condition. For example, the clinical
response to patients with mild to moderately
severe asthma is different to that for patients with
immediately life threatening asthma. This type of
graduated clinical approach has been used quite
successfully in ambulance service protocols for
many years.
– level of training and expertise of the nursing staff
who are initiating the management of the patient
– that is, formatting which allows for RNs with
advanced training to implement more advanced
interventions. RNs without this advanced training
and credentialing cannot perform the advanced
interventions. The use of shaded sections in the NSW Rural Paediatric Emergency Clinical
Guidelines indicate clinical interventions that can only be initiated by RNs who are recognised as Paediatric Advanced Clinical Nurses.
n incorporation of the various legal requirements
for nurses who initiate treatment and administer
medications based on standing orders.
n flexibility - guidelines need to be flexible enough to
allow local input from rural Medical Officers (MOs)
and RNs so that local practices can be incorporated.
n endorsement by relevant committees and divisions
within NSW Health.
n standardisation in the management of specific
paediatric conditions across NSW.
The guidelines are also formatted to follow the accepted
Airway, Breathing, Circulation, Disability (ABCD)
approach for managing paediatric emergency/critical
care patients. These guidelines are not for use in infants less than four weeks of age due to significant
pharmacological and physiological differences.
A number of these guidelines have been developed
from the NSW Health Acute Paediatric Clinical Practice
Guidelines. Where applicable and advised, subsequent
treatment and management should follow the NSW
Health Acute Paediatric Clinical Practice Guidelines.
The aims of the NSW Rural Paediatric Emergency Clinical
Guidelines are to:
n improve the emergency care and outcomes for
paediatric patients in the rural and remote health
care settings of NSW;
n provide readily accessible and user-friendly guidelines
for clinicians providing paediatric emergency care to
patients in rural and remote areas of NSW;
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 2
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
n assist rural and remote EDs in NSW achieve
benchmarking targets and best practice standards
for children with emergency presentations;
n address some of the current professional issues facing
rural and remote RNs by:
– providing a safe framework in which rural and
remote RNs can initiate management and care
of paediatric emergency patients;
– recognising and formalising the advanced role
many rural and remote RNs currently perform
when delivering care to critically ill or injured
paediatric patients with emergency conditions;
– providing a pathway by which credentialed
RNs can work toward continuing professional
development.
Nursing staff using these clinical guidelines are required
to be appropriately educated, skilled and credentialed.
The shaded portions contained in the treatment
guidelines must only be used by RNs who are recognised
as Paediatric Advanced Clinical Nurses.
Paediatric Advanced Clinical Nurses are those RNs
that have advanced knowledge and skills and have
been deemed competent to carry out these advanced
roles using contemporary assessment and ongoing
credentialing processes.
Credentialing of Paediatric Advanced Clinical Nurses (ACN)Registered nurses can be considered eligible to be
credentialed for Paediatric Advanced Clinical Nurse
roles if:
n they have successfully completed an advanced
emergency or critical care nursing course such as the
First Line Emergency Care Course (FLECC),
OR
n Graduate Certificate/Graduate Diploma in Paediatric
Nursing – Emergency stream
AND
n they can demonstrate recent and ongoing knowledge
and experience with managing emergency/critical
care paediatric patients.
Credentialing will be obtained and maintained by:
n completion of competency assessments as
recommended by the Children’s Healthcare Network
Regions in each Local Health District.
n the ACN maintaining appropriate documentation to
allow review of the usage of these rural emergency
guidelines.
Paediatric Advanced Clinical Nurses are required to be
re-credentialed annually or according to the Local Health
District Policy.
It will be the responsibility of the rural Local Health
Districts through their Children’s Healthcare Network
Regions, Critical Care Network Committee and Health
Service Managers to ensure compliance with these
requirements.
Implementation It is intended:
n when a Paediatric Advanced Clinical Nurse
implements these clinical guidelines, a Medical Officer
(MO) will be notified immediately to ensure their
early involvement with the management and care of
the paediatric patient.
n that any medication standing orders contained in
these clinical guidelines will be signed and authorised
by a MO appointed by the Local Health District. This
MO may be one of those servicing the Emergency
Department/s using these Guidelines.
n that MO review is required following the
administration of a drug according to the standing
orders contained within this document as soon as
possible (must be within 24 hours). At the time of
this review the MO must check and countersign the
nurse record of administration on the medication
chart.
n that any medication standing orders contained in
these clinical guidelines will have no legal basis
unless they are approved by the Local Health
District Drug and Therapeutics Committee (or local
hospital Drug Committee if there is no Local Health
District Committee), as specified in NSW Health
PD2013_043 Policy on Medication Handling in
NSW Public Health Facilities, (Section 5.2 Standing
Orders). Each standing order must be signed and
dated by an appropriate senior Medical Officer and
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 3
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
by the Chairperson of the Drug Committee that is
approving the standing order.
The committee must review the standing order
annually and re-sign and date to confirm on-going
approval.
This document should be read in conjuction with the
following documents:
n NSW Health PD2005_042 Guidelines for
Hospitals seeking to extend the practice of health
professionals.
n NSW Health PD2013_043 Policy on Medication
Handling in NSW Public Health Facilities.
n NSW Health PD2009_009 Paracetamol Use.
n NSW Health PD2010_009 Infants and Children:
Acute Management of Gastroenteritis.
n NSW Health PD2011_038 Recognition of a Sick Baby
or Child in the Emergency Department.
n NSW Health PD2013_044 Infants and Children:
Acute Management of Bacterial Meningitis.
n NSW Health PD2013_053 Infants and Children:
Acute Management of Abdominal Pain.
n NSW Health PD2012_056 Infants and Children:
Acute Management of Asthma.
n NSW Health PD2012_004 Infants and Children:
Acute Management of Bronchiolitis.
n NSW Health PD2010_063 Infants and Children:
Acute Management of Fever.
n NSW Health PD2009_065 Infants and Children:
Acute Management of Seizures.
n NSW Health PD2011_024 Infants and Children:
Acute Management of Head Injury.
n NSW Health PD2010_053 Infants and Children:
Acute Management of Croup.
n Australian Medicines Handbook, AMH Children’s
Dosing Companion 2013.
The paediatric clinical practice guidelines have e-learning
modules available at http://doh.edmore.com.au.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 4
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
AbbreviationsABG Arterial Blood Gas
ACN Paediatric Advanced Clinical Nurse
ALS Advanced Life Support
ARC Australian Resuscitation Council
ATS Australasian Triage Scale
AVPU Alert, Voice, Pain, Unresponsive
BSA Body Surface Area
BGL Blood Glucose Level
CPR Cardiopulmonary Resuscitation
CRP C Reactive Protein
CSL Commonwealth Serum Laboratory
CVAD Central Venous Access Device
CXR Chest X-Ray
EAR Expired Air Resuscitation
ECG Electrocardiograph
ED Emergency Department
EDWPR Emergency Department Work Practice Review
EtOH Ethanol
FBC Full Blood Count
FLEC First Line Emergency Care course
GCS Glasgow Coma Score
GIT Gastrointestinal tract
GP General Practitioner
g Gram
hCG Human Chorionic Gonadotropin
hrs Hours
ICU Intensive Care Unit
IM Intramuscular
IO Intraosseous
IV Intravenous
J Joules
kg Kilogram
LFT Liver Function Test
LHD Local Health District
litres/min Litres per minute
LOC Level Of Consciousness
MDI Metered Dose Inhaler
min Minute
MO Medical Officer
mmol/L Millimols per Litre
mL Millilitre
MSU Mid Stream Urine
MVC Motor Vehicle Crash
NETS Newborn and paediatric Emergency
Transport Service
NG Nasogastric
O2 Oxygen
ORS Oral Rehydration Solution
PEFR Peak Expiratory Flow Rate
PO Per Oral
PPE Personal Protective Equipment
PR Per Rectum
RN Registered Nurse
RSV Respiratory Syncytial Virus
SBP Systolic Blood Pressure
SCI Subcutaneous Injection
Sec Seconds
SpO2 Pulse oximetry saturation
Stat Immediately and once only
TBSA Total Body Surface Area
U/A Urinalysis
UEC Urea Electrolytes Creatinine
UO Urine Output
UTI Urinary Tract Infection
VF Ventricular Fibrillation
VT Ventricular Tachycardia
Wt Weight
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 5
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Definitionsn Continuous – Uninterrupted.
n Neonate – Less than 28 days old.
n Infant – One month to twelve months of age.
n Child/Paediatric – One year up to 16th birthday.
These are the definitions used for the purposes of this
document. It is acknowledged that paediatric inpatient
units usually admit 0-16 years [newborns excluded].
ReferencesFuller. J, Schaller-Ayers, J. 2000, Health assessment:
a nursing approach, 3rd edn. Lippincott. Philadelphia.
Australian Resuscitation Council, 2010, Guideline 12.1,
ARC Guidelines.
Australian Resuscitation Council, 2010, Guideline 13.1,
ARC Guidelines.
Children and Young Persons (care and protection ) Act
1998 section 3.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 6
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
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NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 7
Assessing children
SECTION 1
If life-threatening activate your local rapid response protocol immediately
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
IntroductionInfants and children are anatomically and physiologically
different to adults. They have unique communication,
emotional, and developmental needs. Health
professionals performing clinical assessments on sick
children need
to be conversant with these differences and the
subsequent impact on the child’s response to injury
and/or illness.
Assessment of the sick child is always tailored to the
child’s level of distress and tolerance. Interventions to
support the seriously ill or injured child, always follows
the same plan:
n Airway
n Breathing
n Circulation/Fluids
n Disability/Dextrose
n Exposure/Environment
Important advice A number of factors should be taken into consideration
when assessing children in the Emergency Department,
including the presenting problem, the child’s behaviour,
vital signs, oxygen saturation, and the degree of parental/
caregiver concern. All of these factors combine to provide
the nurse with an indication of the severity of illness.
There are, however, a number of clinical signs, which
should always be considered as potentially very serious
and generally, require immediate medical review and
intervention.
These include:
Clinical severity prompts
Airway
– stridor
– choking
– obstruction
Breathing
– no breath sounds on auscultation
– irritability in an infant or restlessness in the older
child (may indicate hypoxia)
– inability of an infant to feed due to breathlessness
– grunting respirations (infants)
Circulation
– pallor
– mottling
– delayed capillary refill greater than 2 seconds
– tachycardia (for age) in an otherwise well looking
child or significant tachycardia in any child
– bradycardia for age
– hypotension
Disability
– lethargy
– poor response to painful stimuli
– readily compliant with painful procedures
– “normal” vital signs in a sick looking child
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 8
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Remember:n Size and relative body proportions change with age.
n Treatment and management regimes are related to
age and weight.
n Infants and children are more prone to hypothermia,
due to their large body surface area to mass ratio.
It is very important to keep them warm.
n Infants and young children are prone to
hypoglycaemia. Check blood glucose level regularly.n Children have unique psychological needs.
All drug doses and fluids are calculated on body
weight. It is essential that all children are weighed
on presentation to the Emergency Department. If
exceptional circumstances exist and this is not possible,
then the following weight for age formula can be used
0-12 months wt kg = (0.5 x age in mths) + 4
1-5 yrs wt kg = (2 x age in yrs) + 8
6-12 yrs wt kg = (3 x age in yrs) + 7
An alternative to ascertaining the weight is the
Broselow™ Paediatric Emergency Tape.
Why children are different The following table provides a brief overview of the
important differences in infants and children and the
subsequent implications for your practice.
Airway and breathing When assessing respiratory rate, rhythm and pattern
count for a full minute.
Note: By approximately 8 years of age a child’s airway
anatomy and physiology approximates that of adults.
Differences Implications
Children less than 2 years have a proportionally large head and short neck.
Shorter and softer trachea.
Greater risk of neck flexion or overextension which may cause tracheal compression and airway obstruction.
Comparatively large tongue, a small mouth and soft oropharynx.
Easily obstructed, damaged and prone to swelling.
Infants less than 6 months of age are preferential nasal breathers.
More easily obstructed by secretions.
Secretions in the nose may impede airway patency.
Narrower airways. More easily obstructed by secretions and foreign bodies.
Diaphragmatic breathers.Impeded diaphragmatic contraction (caused for example by abdominal distension) can increase or lead to respiratory distress.
Epiglottis is horse shoe shaped and projects posteriorly at 45˚.
Intubation can be difficult.
The larynx is high and anterior.A straight blade is preferred when intubating an infant.
Children are more prone to aspiration.
Cricoid ring is the narrowest point of the airway and susceptible to oedema.
Uncuffed tubes are often used.
Intercostal muscle is underdeveloped with fewer type 1 fibres than adults. (Less than 5 years).
Ribs are more horizontal.
These muscles stabilise but do not lift the chest wall. They become easily fatigued and cannot sustain long periods of increased respiratory demand.
The cartilaginous chest wall is more compliant. The child’s ability to maintain functional residual capacity or increase their tidal volume during respiratory distress is compromised.
Chest wall very thin. Respiratory sounds are transmitted more readily.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 9
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Pulse oximetryPulse oximetry should not replace clinical assessment but is a useful adjunct to patient assessment. An age and site appropriate pulse oximetry probe must
be correctly positioned in order to ensure an accurate
reading. Typical paediatric sites are the finger, toe, pinna
(top) or lobe of the ear. Infant sites are the foot or palm
of the hand and the big toe or thumb. Immobile sites are
preferred in wiggling children (eg foot, palm of hand).
RememberWhile pulse oximetry is generally considered a safe
intervention, device limitations and false- positive/
negative results may lead to delayed or inappropriate
treatment. As with all assessments, it is important that
oxygen saturation is considered in terms of the total
clinical picture and not in isolation. Treatment should
never be delayed for a child who looks unwell but who
has an oximetry reading (or any vital sign measure)
within a normal range.
It is important that the oximetry probe is resited at least every two hours, due to the risk of pressure necrosis to the skin.
Oxygen therapyOxygen therapy is recommended to maintain oxygen
saturation (SpO2) greater than 94%.
A Medical Officer must be notified when a child requires
oxygen (O2) and if there are any changes to those
requirements.
When required appropriate delivery systems that may be
chosen and implemented include:
Paediatric non-rebreather bag and mask – for
children requiring high flow oxygen. The reservoir
bag must remain inflated and the oxygen flow rate
regulated so that the bag will only deflate by one third
on inspiration. Requires a minimal oxygen flow rate of
10 litres per minute. The bag must be pre-inflated with
oxygen before placing the mask on the child.
Simple face mask – available in two sizes and
appropriate for moderate to high oxygen flow rates.
Requires a minimum flow rate of at least 6 litres per
minute to effectively clear expired gases, however this is
dependent upon the child’s individual tidal volume.
Disposable infant head box – for infants requiring
oxygen where other methods of oxygen delivery are
not suitable. The headbox is placed over the infant and/
or the head of an infant lying in the supine position. To
ensure adequate carbon dioxide washout, the minimum
oxygen flow rate into the hood is 10 litres per minute.
Checking of oxygen concentration within the hood with
an oxygen analyser if available is desirable to confirm
oxygen content within the hood.
Bag-valve-mask – for children requiring assistance/
positive pressure ventilation. Use age appropriate bag
size. Minimum flow rate is 10 litres per minute. Ensure
valve is opening with breathing.
Low flow nasal prongs – Available in four sizes and
appropriate for conscious children requiring low flow
oxygen to maintain oxygen saturations. Maximum flow
rate is 3 litres per minute. Low flow nasal prongs are not
suitable for acutely unwell children as they cannot deliver
high rates of oxygen.
Refer to Appendix 3 for further information on paediatric
oxygen therapy.
CirculationPallor, tachycardia, restlessness, irritability, decreased
central capillary refill and cool peripheries may be
evidence of the early stages of circulatory failure.
Later signs include a slowing heart rate and decreased
volume of peripheral pulses. It is important also to
remember that fluid loss may be hidden and therefore
underestimated. The child with any of the above clinical
signs requires early intervention to restore circulating
blood volume with close observation and monitoring
maintained.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 10
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Differences Implications
Larger total circulating blood volume per kilogram of body weight than adults.
(Eg Infants have a blood volume of 80 mL/kg).
A relatively small amount of blood loss can be significant eg a 100 mL haemorrhage in a one-year-old child constitutes a loss of approx. 7-10% of the total circulating blood volume.
Higher basal metabolic rate - 2 to 3 times that of adults. Further demands are made by illness.
Vital signs are only one indication of a child’s circulatory status and can only be correctly interpreted within the context of a full physical assessment.
Normal Paediatric Ranges
Age – Years weight – Kg HR/min RR/min
less than 30 days 3.5 100-160 30-60
6 months 7 100-160 30-40
1 10 100-160 30-40
2 12 90 -140 20-40
4 16 90 -140 20-40
6 20 80 -120 20-30
8 24 80 -120 20-30
10 30 80 -120 20-30
greater than 12 40+ 60 -100 15-20
Expected Systolic Blood Pressure = 85+ (age in yrs x 2) mmHg
NSW Health Between The Flags, Standard Paediatric Observation Charts 2010
Heart rate: although there is no strong evidence for this, values measured 10% outside the normal range should be
considered as moderately severe and values 20% outside the normal range considered severe. Interpretation must
always occur in the context of the child’s activity level.
Blood Pressure The normal systolic blood pressure for a child older than
1 year can be calculated using the above formula. Use of
the correct sized blood pressure cuff is crucial. The cuff
width must be 2/3 the length of the upper arm or thigh.
RememberBradycardia is an ominous sign in children and indicates
cardio-respiratory collapse.
Hypotension is a late and pre terminal sign of circulatory
failure in children.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 11
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
When considering vital signs within “normal range” it is important to remember that these should always be considered in relation to the presenting problem and not in isolation. For example, a febrile child would be expected to be tachycardic/tachypnoeic, and a “normal” heart or respiratory rate would warrant close observation and further review. Similarly, significant tachycardia under any circumstance should also be investigated, while bradycardia in any child is an ominous sign and requires immediate medical review and intervention.
Capillary refill time measured centrally on the sternum
(not peripherally ie fingers and toes) also provides a
good indication of circulatory status. Using a thumb,
apply pressure to the sternum for 5 seconds. Capillary
refill should be equal to or less than 2 seconds. A slower
response indicates poor perfusion.
Fluid and electrolytes
Children have Implications
High percentage of total body weight is water.
Greatest percentage of fluid located in the extracellular compartment.
A relatively small amount of fluid loss can lead to
circulatory collapse as adequate intracellular fluids
cannot be drawn on to support the circulatory system.
Large surface area to body weight ratio – greater insensible fluid losses.
Insensible fluid losses are influenced by illness, and
are increased further if the child is febrile, tachypnoeic,
or tachycardic.
High metabolic rate.
Illness increases the already high metabolic rate and as
a result insensible fluid loss. This in turn increases fluid
requirements.
Immature renal function.
Less efficient in excreting waste, concentrating or
diluting urine, and conserving sodium in times of fluid
loss or overload.
Increased fluid requirements per kg of body weight. Greater amount of fluid per kilogram of body weight is required than for the older child or adult.
Signs of dehydration
Mild (3%) Moderate (5%) Severe (10%)
Same as no clinical signs of dehydration plus
Same as mild plus
Lethargy
Tachycardia
Reduced skin turgor
Sunken eyes
Abnormal respiratory pattern
Same as moderate plus
Dry mucous Membranes
Poor perfusion – mottled, cool
limbs/slow capillary refill/altered
consciousness
Mild Tachycardia
Shock - thready peripheral pulses with
marked tachycardia and other signs of
poor perfusion stated above
Source: NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 12
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Maintenance fluid requirements As with medications, calculations for maintenance
paediatric fluids are based on the child’s body weight.
A child’s fluid requirements may alter depending on
the clinical problems they have been hospitalised with.
Therefore, once maintenance fluid requirements have
been calculated, actual fluid requirements may need to
be modified according to the child’s clinical condition.
For example, children presenting with dehydration
will require the calculation of maintenance fluid, then
additional fluid will need to be provided depending
on the degree of dehydration (see NSW Health PD
2010_009 Infants and Children: Acute Management of
Gastroenteritis).
One method for calculating maintenance fluid
requirements is outlined in the table below. Other
methods are described in the NSW Health PD
2010_009 Infants and Children: Acute Management of
Gastroenteritis.
Maintenance fluid requirements per day
First 0-10kg 100 mL/kg/24hrs
Next 11–20kg Plus 50 mL/kg/24hrs
Next greater than 20kg Plus 20 mL/kg/24hrs
NSW Health PD 2010_009 Infants and Children: Acute Management of Gastroenteritis
Maintenance fluid requirements per hour
First
0-10kg4 mL/kg/hr kg x 4 mL/hr = mL/hr
Next
11–20kg2 mL/kg/hr Plus kg x 2 mL/hr = mL/hr
Next greater
than 20kg 1 mL/kg/hr Plus kg x 1 mL/hr = mL/hr
NSW Health PD 2010_009 Infants and Children: Acute Management of Gastroenteritis Note: Rate should not be greater than 100mL/hr
Monitoring fluid balance As children are predisposed to imbalances of fluid and
electrolytes, an accurate fluid balance record should
be kept for all children admitted to the Emergency
Department. This is particularly important for children
receiving intravenous fluids and for those under 3 years
of age.
Management of intravenous therapy
Checklist for safe administration of IV fluids
n IV fluids administered via burette
n Pump with paediatric setting available where possible
n Strapping - non-restrictive, site visible, limb
immobilised with splint
n No more than 2 hours fluid in burette
n Site checked and recorded hourly for redness/swelling
n Fluid level checked hourly and recorded
n Assessment for signs of over hydration or
dehydration
DisabilityRapid assessment of consciousness can be made by
using the AVPU scale:
A AlertV responds to VoiceP responds only to PainU Unresponsive to pain
For a more detailed assessment of LOC a modified
paediatric GCS should be used.
Further discussion regarding the AVPU and the modified
paediatric Glasgow Coma Scale can be found in
Appendix 4.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 13
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
The following table provides an overview including alerts when further investigation is required.
Age Normal behaviour Alerts
Infant
(less than 1 year)
Good eye contact.
Orientates to faces.
Visually track bright objects.
Moves limbs spontaneously.
Flexion is a normal body posture.
Able to be consoled by primary carer.
No eye contact.
Irritable.
High pitched or very weak cry.
Flexed rigid extremities/flaccid/unresponsive.
Toddler
(1-3 years)
Protest when separated from parents/primary carer.
Demonstrate stranger anxiety
Able to be consoled by primary carer.
Extreme irritability.
Lethargic and unresponsive.
Fails to protest when the parents leave.
Preschooler
(3-5 years)
Mistrustful and afraid of strange environments.
Curious about equipment and events.
Able to be consoled by primary carer.
Trusting and readily compliant.
Irritable and uncooperative.
Lethargic and unresponsive.
Shows no interest in events and procedures.
School age
(5-10 years)
Responds readily to painful stimulus. Will try to withdraw from pain.
Limited response and protest.
RememberGenerally parents know their children best, and recognise when they are unwell. Always listen to parents concerns.
Exposure and environmentInfants and children are more prone to hypothermia
due to their large body surface area to mass ratio. It
is very important to keep them warm whilst ensuring
appropriate exposure for assessment.
Remember Infants and young children are prone to hypoglycaemia. Check blood glucose level regularly.
Psychological considerationsThe child’s response to injury and illness is influenced
by previous experiences and their developmental level.
This is influenced by their age, cognitive abilities,
communication skills and family dynamics.
Emergency Departments are potentially noisy and
frightening places for children and their carers.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 14
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
The following table is a summary of the key developmental phases during childhood and offers some practical
suggestions for your nursing practice.
Age Strategies to minimise anxiety in the ED
Infant
(less than 1 year)
Minimise separation from primary carer.
Use objects familiar to child.
Soothing gentle approach.
Use distraction techniques.
Prepare primary carer and encourage them to soothe and comfort the infant.
Toddler
(1-3 years)
Encourage toddlers to participate in choices.
Where possible maintain routine.
Allow loud protest to procedures.
Gently restrain by wrapping or holding during procedures.
Explain procedures immediately prior to them occurring and provide age appropriate explanations.
Avoid separation from primary carers where possible.
Provide praise.
Preschooler
(3-5 years)
Provide age appropriate accurate information.
Minimise separation from parents/primary carer.
Provide choices (when possible).
Age appropriate explanations.
Procedural play – allow the child to handle equipment.
Use puppets, dolls etc.
Allow verbalisation of fears and feelings.
School age
(5-12 years)
Include parents/primary carer.
Include the child in their care.
Explain procedures in advance.
Use models, drawings explanations.
Provide privacy.
Allow them to verbalise their fears and ask questions.
Adolescents
(13-15 yrs)
Encourage choices and decisions in care.
Realistic and honest explanations.
Models and diagrams used in explanations.
Provide and respect privacy.
Include the parents but consider adolescents needs and requests.
Encourage questions and clarifications.
Adapted from Colizza D, Prior M, and Green P. 1996, The Emergency Department Experience: The Developmental and Psychological Needs of Children. Topics in Emergency Medicine 18: 3. 27-40.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 15
Assessing children Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
References
APLS Manual Australian Edition (5th) 2011 Wiley &
Blackwood.
Colizza D. Prior M. and Green, P. 1996, The Emergency
Department Experience.
The Developmental and Psychological Needs of Children.
Topics in Emergency Medicine 18: 3. 27-40.
Hill E. and Stoneham M.D. 2000, Practical applications
of pulse Oximetry, Update in Anaesthesia, 11:4. 1-2.
Hunter New England Area Health Service, 2005,
Paediatric Oxygen Therapy, Hunter Emergency Services
Policy, Hunter Area Emergency Guidelines Committee.
Kilham, H., Alexander, S., Wood, N., Isaacs, D.
Paediatrics Manual - The Children’s Hospital at
Westmead Handbook (2nd Edition 2009).
Lee C.A. Barrett C.A. and Ignatavicius, 1996, Fluid and
Electrolytes. A Practical Approach (4th edn.) Philadelphia,
F.A. Davis. Chapter 2 pp 14-28.
Mackway-Jones, K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. BMJ Blackwell Publishing
Group Limited, Massachusetts.
NSW Child Health Network Paediatric Resuscitation Card
2012.
NSW Health PD 2010_009 Infants and Children: Acute
Management of Gastroenteritis.
Southall D. Coulter B. Ronald C. Nicholson S. Parke
S. 2002, International Child Health Care: A practical
manual for hospitals worldwide. BMJ Blackwell
Publishing Group, London.
Wong D. 1999, Balance and imbalance of body fluids.
In D.L. Wong. 1999, Nursing care of infants and children.
St Louis: Mosby.
NSW Health Between The Flags. Standard Paediatric
Observation Charts 2010.
This page has been left blank intentionally
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 17
SECTION 2
If life-threatening activate your local rapid response protocol immediately
Recognition of a sick child Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Remember: Generally parents know their children best and recognise when they are unwell. Listen to parents concerns.
Clinical severity prompts
Airway
– obstruction - complete
partial - stridor
– apnoea - including history of apnoea
Breathing
– bradypnoea
– tachypnoea
– chest recession
– noises; grunting, gasping, wheeze
– accessory muscle use
– nasal flaring
– oxygen saturations less than 94% in room air
Circulation
– tachycardia/bradycardia
– hypotension (late sign and is indicative of
impending arrest)
– capillary refill greater than 3 seconds (centrally)
– agitation
– poor perfusion
– neurovascular compromise
– altered alertness, level of activity/consciousness
– signs of dehydration
Disability
– AVPU - only responding to pain or unresponsive
– pain
– hyper/hypoglycaemia
– fever greater than 38.50 C. If less than 3 months
of age fever greater than 380 C per axilla or
hypothermic
– rash – non blanching petechiae or purpura
History prompts
n Age especially neonate (less than 28 days old)
n Parental concern
n Onset
n Events – trauma or history of trauma
n Re-presentation
n Co-morbidity
n Immunosuppressed
n Fluids in and out past 24 hours
n Immunisation status
n Exposure to anyone else who is sick
n Relevant past history
n Medication history/management
n Child at risk
n Allergies
Recognition of a sick child
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 18
Recognition of a sick child Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Apply O2 via a non-rebreather mask to maintain SpO2 greater than 94%
Circulation Skin temperature
Pulse – Rate/Rhythm
Capillary refill (sternum)
Blood pressure
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, BGL and blood culture. Consider group and hold in trauma patients
Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gm in 24 hours.
Oral Oxycodone 0.1 mg/kg (maximum dose 5 mg) stat
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary) to a maximum dose of 10 mg) OR If child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)
Per axilla
Collect urine for culture and analysis
Investigate hydration status
Fluid balance chart
Specific treatment
SpO2 Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 19
Recognition of a sick child Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Paracetamol
Precaution: Prior
to administration
determine recent
administration
of any medicines
containing
Paracetamol
(minimum dosing
interval is four
hours)
Dose is recommended for patients of normal or average build.*
15mg/kg/dose 4 hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral Stat
Drug Dose Route Frequency
Oxycodone 0.1 mg/kg (maximum 5 mg) Oral Stat
Fentanyl 1.5 microgram/kg (maximum 75 micrograms total dose)
Intranasal 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)
Morphine sulphate
0.1 mg/kg IV/IO Stat. (repeat once in 10 minutes if necessary to a maximum dose of 10 mg)
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride
Child less than 25kg; 0.5 mg
Child greater than 25kg; 1 mg
IM Stat
0.9% Sodium Chloride
20 mL/kg IV/IO Bolus
0.9% Sodium Chloride
2 mL flush IV As required
* Refer to NSW Health PD2009_009 Paracetamol Use for other patients
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 20
Recognition of a sick child Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Precautions and notes.n Remember the younger patient may present with
more subtle symptoms and signs and the level of
suspicion should be higher.
n An age/developmentally appropriate pain scale must
be used to assess pain in children (refer Appendix 7).
n This guideline should be read in conjunction with
NSW Health PD2011_038 Recognition of a Sick Baby
or Child in the Emergency Department.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. BMJ Blackwell Publishing
Group Limited, Massachusetts.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Northern Sydney Health Paediatric Triage Tool, 2004,
Adapted from Consistency of triage in Victorian
Emergency Department Education and Quality Report.
July 2001. Monash Institution of Health Services Research,
Clayton Victoria.
NSW Child Health Networks Paediatric Information Card,
2007.
NSW Health PD2011_038 Recognition of a Sick Baby or
Child in the Emergency Department.
NSW Health PD2009_009 Paracetamol Use <accessed
06/03/14>
Australasian Paediatric Endocrine Group National
Evidence-Based Clinical Care Guidelines for Type 1
Diabetes for Children, Adolescents and Adults 2011
http://www.apeg.org.au/Portals/0/guidelines1.pdf
<accessed 17/03/14>.
Australian Resuscitation Council Medications & Fluids
in Paediatric Advanced Life Support 2010 http://www.
resus.org.au/policy/guidelines/section_12/medications_
fluids_in_paediatric.htm <accessed 06/03/14>.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 21
SECTION 3
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
Any acute onset of hypotension or bronchospasm
or upper airway obstruction where anaphylaxis is
considered possible even if typical skin features are not
present.
OR Any acute onset illness with typical skin features
(urticarial rash or erythema/flushing, and/or angioedema)
PLUS involvement of respiratory and/or cardiovascular
and/or persistent severe gastrointestinal symptoms.
History prompts
n Onset
n Exposure to known allergen for the patient
n Associated symptoms
– respiratory distress, peripheral vasodilation,
hypotension, urticaria, generalised redness and peri
orbital oedema
– young child may present floppy and pale
n Flushing, urticaria and angioedema can be absent in
up to 20% of cases
n Gastrointestinal symptoms: vomiting, abdominal pain,
incontinence
n Relevant past history
n Medication history
n Allergies
n History of asthma/atopy
n Introduction of new foods
Anaphylactic Reaction
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 22
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
PositionDo not allow child to stand or walk. If breathing is difficult allow them to sit in position of comfort with carer.
Cease/remove causative agent
Airway Assess patency
Stridor
Maintain airway patency
If stridor present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat: If symptoms not reversed Adrenaline may be given every 5 minutes as needed.
**If hoarse voice present also consider nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose
Hoarse voice and/or difficulty talking
Breathing Respiratory rate and effort
SpO2
Wheeze
If patients cannot inhale adequately to use an MDI and spacer or requires oxygen therapy
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%.
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
If wheeze present give IM *Adrenaline 0.01mL/kg of 1:1,000 stat if symptoms not reversed Adrenaline may be given every 5 minutes as needed.
If wheeze present give Salbutamol: child less than 20kg 6 puffs Salbutamol 100 micrograms dose MDI + spacer stat; child greater than 20kg 12 puffs Salbutamol 100 micrograms dose MDI + spacer stat
Child less than 20kg 2.5 mg Salbutamol nebule stat; child greater than 20kg 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Circulation Skin colour
Pulse – rate/rhythm
Blood pressure
Capillary refill
Cardiac monitor
If signs of shock give IM Adrenaline 0.01mL/kg of 1:1000 stat if symptoms not reversed Adrenaline may be repeated every 5 minutes as needed.
IV cannulation/IO needle insertion
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils Monitor LOC frequently
Measure and test
Temperature
Fluid input/output
Per axilla
Fluid balance chart
Specific treatment
No response to IM Adrenaline and patient presents with signs of cardio respiratory collapse
IV/IO ***Adrenaline 0.1mL/kg of 1:10,000 Follow paediatric Basic Life Support algorithm
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 23
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
*Adrenaline 0.01mL/kg of 1:1,000 IM Stat. If symptoms not reversed Adrenaline may be repeated every five minutes as needed.
** Adrenaline 0.5 mL/kg of 1:1,000 (maximum 5 ml undiluted) Nebuliser Stat. If symptoms not reversed second dose may be given 10 minutes after initial dose
*** Adrenaline 0.1mL/kg of 1:10,000 IV/IO Consider if cardio respiratory arrest
Salbutamol Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)
Child greater than 20kg; 12 puffs of 100 microgram dose = (1200 micrograms)
Metered dose inhaler via spacer
Stat then repeat as required
Salbutamol Child less than 20kg; 2.5 mg nebule
Child greater than 20kg; 5 mg nebule
Inhalation
Nebuliser with a minimum oxygen flow rate of 8 litres per minute
Child less than 20kg; 2.5 mg nebule stat
Child greater than 20kg; 5 mg nebule stat
0.9% Sodium Chloride
20 mL/kg bolus IV/IO Bolus
0.9% Sodium Chloride
2 mL flush IV/IO As required
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:1,000 IM
equates to Adrenaline 0.01 mL/kg of 1:1,000 IM.
n **Nebulised Adrenaline is not recommended as
first-line therapy, but may be a useful adjunct to IM
Adrenaline if upper airway obstruction is present
n ***Adrenaline 10 micrograms/kg of 1:10,000 IV/IO
equates to Adrenaline 0.1mL/kg of 1:10,000 IV/IO
n For effective salbutamol delivery to the bronchial tree
the oxygen flow rate should be set at 8 litres per
minute
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 24
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
n Skin urticaria is absent in approximately 20% of
cases.
n Systemic allergic reactions can occur with urticaria,
angioedema and rhinitis, but are not anaphylactic
reactions as they are not life threatening.
n Death caused by anaphylactic reaction occurs most
commonly in the first 45 minutes after the patient
has contact with an allergen.
n Adrenaline is the most important drug for the
treatment of an anaphylactic reaction.
n The best site for intramuscular (IM) Adrenaline is the
anterolateral aspect of the middle third of the thigh
– the needle needs to be long enough to ensure that
the Adrenaline is injected into the muscle (Soar et al
2008:162).
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach, 4th edn. The child in shock, pp
107-109, BMJ Blackwell Publishing Group Limited,
Massachusetts.
Children’s Hospital Westmead Emergency Department
Policy for Anaphylaxis and Allergy, 2005.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
Royal Children’s Hospital Melbourne Policy on
Anaphylaxis 2011.
United Bristol Healthcare, Directorate of Children’s
Services, Nebuliser Guidelines 2003, http://www.
bristolpaedresp.org.uk/BCHNebuliserProtocol18.11.2003.
pdf <accessed 17/03/14>.
Soar J, Pumphrey R, Cant A, et al. for the Working
Group of the Resuscitation Council (UK). 2008.
‘Emergency treatment of anaphylactic reactions:
Guidelines for health care providers’, Resuscitation, vol
77, (2), no. 2.
Australian Prescriber Anaphylaxis Wallchart (2011)
Australian Prescriber August 2011, Vol 34 No. 4.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 25
SECTION 3
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Corresponds with either mild, moderate or severe
scale as described below
n Age less than 6 months
n Poor response to initial treatment
n Pre-hospital treatment- manage as more severe than
clinical signs indicate
n Inability to maintain own airway
History prompts
n Onset
n Parental concern
n Medication history
n Allergies
n Immunisation status
n Representation within 24 hours
n Previous history of severe croup
n Known structural airway abnormality
n Severe obstruction prior to presentation (also consider
foreign body)
Clinical manifestations of croup
Mild Moderate Severe
Stridor Nil or intermittent Persisting stridor at rest Persisting stridor at rest
Cough Barking Barking Barking or absent
Increased Respiratory Effort
No Some tracheal tug and/or chest wall recession
Marked tracheal tug and/or chest wall recession
Cyanosis/pallor No No Possibly
Level of Consciousness
Alert May be distressed but can be placated
Apathetic or restless agitated decreased LOC
Croup
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 26
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency
Severe croup
Maintain airway patency
Keep child calm
Minimise interventions
Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted). If symptoms not reversed second dose may be given 10 minutes after initial dose then oral *Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication give nebulised Budesonide 2 mg stat
Breathing Respiratory rate and effort
SpO2
Mild
Moderate
Severe
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%.
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Continuous monitoring
No specific treatment
*Oral Dexamethasone 0.3 mg/kg stat OR if unable to tolerate oral medication nebulised Budesonide 2 mg stat
Nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 ml undiluted) repeat at 10 minutes if required plus *Oral Dexamethasone 0.3 mg/kg stat or nebulised Budesonide 2 mg stat if unable to tolerate oral medication
Do not disturb child unnecessarily
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Colour
Monitor vital signs frequently but do not disturb child unnecessarily
Disability AVPU/GCS Monitor LOC frequently
Keep child calm, minimise interventions
Specific treatment
Severe croup only Give nebulised Adrenaline 0.5 mL/kg of 1:1,000 stat (maximum 5 mL undiluted) If symptoms not reversed second dose may be given 10 minutes after initial dose
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 27
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Adrenaline 0.5 mL/kg of 1:1,000 adrenaline (maximum 5mL) undiluted
Nebulised Stat. If symptoms not reversed second dose may be given 10 minutes after initial dose
*Dexamethasone 0.3 mg/kg Oral Stat
Budesonide 2 mg (1mg/2mL neb) Nebulised Stat
Prednisolone 1 mg/kg Oral Stat
Precautions and notes.n *If oral Dexamethasone is not available administer
oral Prednisolone 1 mg/kg stat.
n Oxygen saturations may be near normal in severe
croup, yet significantly lowered in some children
with mild to moderate croup.
n For ongoing management refer to NSW Health
PD2010_053 Infants and Children: Acute
Management of Croup.
ReferencesNSW Health PD2010_053 Infants and Children: Acute
Management of Croup.
Mackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. BMJ Blackwell Publishing
Group Limited, Massachusetts.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 28
SECTION 3
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
If life-threatening activate your local rapid response protocol immediately
Clinical severity prompts
n Loss of consciousness
n Ineffective cough and increasing dyspnoea
n Inability to vocalise
n Apnoea
n Inability to establish patent airway
History prompts
n Universal choking sign (clutching the neck with the
thumbs and fingers) may be seen in older children
n Sudden onset of respiratory distress
n Paradoxical chest movements
n Associated symptoms: sudden onset of cough,
gagging and/or stridor
Assessment Intervention
PositionPosition of comfort with carerIf unconscious, supine with head tilt/chin lift and jaw thrust
Airway Assess patency
Partial Obstruction
Effective cough
Severe Obstruction
Ineffective cough and conscious
Ineffective cough and unconscious
Maintain airway patency
Encourage coughing
Support and assess continuously
Perform 5 back blows
If the obstruction is not relieved perform 5 chest thrusts
Still not relieved continue alternating, 5 back blows with 5 chest thrusts
Open the mouth and carefully attempt to remove any visible object
Unable to remove foreign body-Commence CPR
Continuously reassess airway for presence of foreign body
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Colour
Cardiac Monitor
Signs of respiratory/cardiac failure commence CPR
Monitor vital signs frequently
Disability AVPU/GCS Monitor LOC frequently
Specific treatment
Severe obstruction – Ineffective cough and unconscious
Unable to remove foreign body - Commence CPR
Document assessment findings, interventions and responses in the patient’s healthcare record
Foreign Body
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 29
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
Precautions and notes.n Back blows can be performed by placing the baby/
child along one of the rescuers arms in a head-down
position, with the rescuers hand supporting the
infant’s jaw in such a way as to keep it open, in the
neutral position. The rescuer then rests their arm
along the thigh, and delivers five back blows with the
heel of the free hand.
n If the child is too large to allow the use of the
single-arm technique, the same manoeuvres can be
performed by laying the child across the rescuer’s
lap. Older child (over 9 years) manage as for adult
choking-lay supine, turn onto side deliver up to 5
back blows, turn supine and perform chest thrusts.
n To perform chest thrusts identify the same landmark
points used for cardiac compressions. Chest thrusts
are given in the same position however are sharper
and delivered at a slower rate (one per second).
The infant should be placed in a head downwards-
supine position across the rescuers thigh. Children if
conscious may be treated in the sitting or standing
position, if unconscious-lying down.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. The child with breathing
difficulties, pp 80. BMJ Blackwell Publishing Group
Limited, Massachusetts.
Australian Resuscitation Council, 2010, Guideline 4:
Airway.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 30
SECTION 3
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Child seizing on arrival to the ED
n Unresponsive to pre-hospital treatment
n Seizure lasting greater than five (5) minutes
n Altered level of consciousness
n Inability to maintain own airway
History prompts
n Onset
n Events – mechanism of injury
n Fever/current febrile illness
n Associated symptoms:
– altered level of consciousness, pale, sweaty,
incontinence
n Relevant past history
n Medication history
n Allergies
Assessment Intervention
Position
Position of comfort with carer
Do NOT restrain the patient
Lie supine/left lateral (after tonic phase and clonic movements cease)
Keep carer at hand
Airway Assess patency Maintain airway patency
Consider oro or naso pharyngeal airway
Stabilise the C-spine with in-line immobilisation (if there is a possibility of injury)
Breathing Respiratory rate and effort
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Stop the seizures
Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR
IM/IV/IO Midazolam 0.15 mg/kg stat and repeat (once only) after 5 minutes if required
It may be difficult to adequately manage the patient’s airway and breathing until the seizures have been stopped. Once this has occurred, it will be necessary to reassess/treat/maintain the patient’s airway and breathing.
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure (post ictal)
Cardiac monitor
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs continuously
Seizures
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 31
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils reactivity post ictal
BGL
Monitor LOC frequently
Measure GCS post ictal
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, Calcium, Magnesium, Blood Culture
Collect urine for culture and analysis
Nil by mouth
Fluid balance chart
Specific treatment
Stop the seizures Buccal Midazolam 0.3 mg/kg (to a maximum of 10mg) stat and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Document assessment findings, interventions and responses in the patient’s healthcare record
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5mg
Child greater than 25kg; 1mgIM Stat
Midazolam 0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IO Stat and repeat (once only) after 5 minutes if required
Midazolam 0.3 mg/kg (to a maximum of 10mg)
BuccalStat and repeat (once only) after 5 minutes if required
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 32
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
Precautions and notes.n Warning: Respiratory and cardiovascular depression
can be severe after the administration of Midazolam
and requires close monitoring and treatment.
n Observe for features of the seizure and document.
n For ongoing management refer to NSW Health
PD2009_065 Infants and Children: Acute
Management of Seizures.
ReferencesLowenstien D.H. Alldredge B.K. 1998, Current concepts:
status epilepticus.
The new journal of medicine. Vol. 338. No 14,
pp 970 – 976.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
NSW Health PD2009_065 Infants and Children: Acute
Management of Seizures.
NSW Health PD2009_009 Paracetamol Use <accessed
06/03/14>.
Australian Paediatric Endocrine Group, Clinical Practice
Guidelines, Type One Diabetes in Children and
Adolescents. Canberra, Australia, National Health
and Medical Research Council, 2005.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life Support;
December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 33
SECTION 3
If life-threatening activate your local rapid response protocol immediately
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
ALERT: The most common error in the management of an unconscious patient is the inadequate management of Airway,
Breathing and/or Circulation
Clinical severity prompts
n Glasgow Coma Scale (GCS) of less than 9
n Inability to maintain own airway
History prompts
n Onset
n Events – mechanism of injury
n Associated preceding symptoms
n Relevant past history
n Medication history
n Allergies
Assessment Intervention
Position Lie supine
Airway Assess patency Maintain airway patency
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Consider oropharyngeal airway
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology
If shocked including: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Continuous cardiorespiratory monitor
If asystolic or bradycardic - refer to BLS/ALS flowchart
Unconscious Patient
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 34
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration
Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Collect blood for FBC, UEC, Blood cultures, consider toxicology, (consider group and hold in trauma patients)
Nil by mouth
Specific treatment
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg/dose (maximum 2 mg) repeat as necessary.
Document assessment findings, interventions and responses in the patient’s healthcare record
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration.
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg IM Stat
Naloxone 0.1 mg/kg/dose (maximum 2 mg) IV/IO/IM Stat repeat as necessary.
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 35
Airway Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notes.n Consider causes – refer to specific Guidelines if
required eg:
– head injury
– anaphylaxis
n Be alert for acute opiate withdrawal after the
administration of Naloxone. The half-life of Naloxone
is much shorter than the opiate. Repeated doses of
Naloxone may be required.
n If IV/IO access is unavailable, both doses of Naloxone
may be given IM, although it should be noted that
this is not ideal as the IM route will take longer to
take effect.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. The child in shock, pp
107-109, BMJ Blackwell Publishing Group Limited,
Massachusetts.
NSW Health GL2012_003 Rural adult emergency Clinical
guidelines 3rd Edition Version 3.1.
Australian Paediatric Endocrine Group: Clinical Practice
Guidelines: Type One Diabetes in Children and
Adolescents. Canberra, Australia, National Health and
Medical Research Council, 2005.
NSW Health PD2009_065 Infants and Children: Acute
Management of Seizures.
Royal Children’s Hospital Melbourne Paediatric
Pharmacopoeia http://pharmacopoeia.hcn.com.
au/?acc=36422<accessed 06/03/14>.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
This page has been left blank intentionally
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 37
SECTION 4
If life-threatening activate your local rapid response protocol immediately
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
If life-threatening activate your local rapid response protocol immediately
Clinical severity prompts
n Correspond with either mild, moderate, severe or life-
threatening scale as described below
n Representation within 24 hours
n Pre hospital treatment
n Inability to maintain own airway
History prompts
n Onset
n Associated symptoms
n Relevant past history
n Medication history
n Trigger factors
n Past presentation/s admission/s (ICU/HDU/intubation)
n Allergies
n Age less than 12 months (exclude differential diagnosis)
n Parental concern
n Immunisation status
Clinical manifestations of acute Asthma
Mild Moderate *Severe *Life-threatening
Altered consciousness
No No Agitated Agitated, confused, drowsy
Accessory muscle use
No Minimal Moderate Severe
Oximetry in air Greater than 94% 90-94% Less than 90% Less than 90%
Talks in Sentences Phrases Words Words/Unable to talk
Pulse rate Normal for age Tachycardia Marked tachycardia Marked tachycardia or bradycardia#
Central cyanosis No No Likely to be present Likely to be present
Wheeze on auscultation
Variable Moderate-loud Often quiet Often quiet
Physical exhaustion
No No Yes Yes
Modified from: the National Asthma Council Asthma Management Handbook, 2006.* Any of these features indicate the episode is severe or life-threatening. The absence of any feature does not exclude a severe or life-threatening attack.# Bradycardia may be seen when respiratory arrest is imminent.
SECTION 4
Asthma
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 38
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
PositionSit upright
Position of comfort with carer
Airway Assess patency
If the patient shows signs of asthma associated with anaphylaxis (exhibits decreasing LOC, increasing cyanosis of lips/mouth and bradycardia)
Maintain airway patency
If the patient has asthma associated with anaphylaxis give IM *Adrenaline 0.01mL/kg of 1:1,000 stat (one dose only)
Breathing Respiratory rate and effort
SpO2
Use of accessory muscles
Mild asthma
Moderate asthma
If patient cannot inhale adequately to use an MDI and spacer or require oxygen therapy
Severe asthma
Life-threatening asthma
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer stat
**Consider oral Prednisolone 1 mg/kg stat
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely; Child greater than 20kgs; 12 puffs Salbutamol 100 micrograms MDI + spacer 3 x 20 minutely
Oral Prednisolone 1 mg/kg stat
Child less than 20kg; 2.5 mg Salbutamol nebule 3 x 20 minutely; Child greater than 20kg; 5 mg Salbutamol nebule 3 x 20 minutely. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available
Salbutamol: Load 4 mL of undiluted salbutamol nebule into nebuliser and aim for cannister to be 1/2 to 2/3 full at all times
Ipratropium Bromide:
Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely
Oral Prednisolone 1 mg/kg stat or if oral not tolerated IV/IO Methylprednisolone 1 mg/kg stat
Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available
Salbutamol:
Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and top up as required
Ipratropium Bromide:
Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely
IV/IO Hydrocortisone 4mg/kg OR Methylprednisolone 1 mg/kg stat
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 39
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Cardiac monitor
IV cannulation/IO needle insertion/pathology; severe/life-threatening asthma
Monitor vital signs frequently
Disability AVPU/GCS Monitor LOC frequently
Measure and test
Pathology
Temperature
Collect blood for UEC, Venous Blood Gases if severe or life-threatening
Specific treatment
Severe/life-threatening Give inhaled Salbutamol continuous nebulised therapy. Give inhaled Ipratropium Bromide at the same time if available
Salbutamol
Load 4 mL of undiluted salbutamol nebule into nebuliser and aim for cannister to be 1/2 to 2/3 full at all times.
Ipratropium Bromide
Child less than 20kg; 250 micrograms 3 x 20 minutely; Child greater than 20kg; 500 micrograms 3 x 20 minutely
IV/IO Hydrocortisone 4mg/kg OR Methylprednisolone 1 mg/kg stat
Document assessment findings, interventions and responses in the patient’s healthcare record
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
Salbutamol
Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)
Child greater than 20kg; 12 puffs of 100 microgram dose = (1200 micrograms)
Inhalation
MDI + Spacer
Mild:
Child less than 20kg; 6 puffs stat
Child greater than 20kg; 12 puffs stat
Moderate:
Child less than 20kg; 6 puffs 3 x 20 minutely
Child greater than 20kg; 12 puffs 3 x 20 minutely
Salbutamol
Child less than 20kg;
2.5 mg nebule
Child greater than 20kg; 5 mg nebule
Inhalation
Nebuliser with a minimum flow rate of 8 litres per minute
Mild:
Child less than 20kg; 2.5 mg nebule stat
Child greater than 20kg; 5 mg nebule stat
Moderate:
Child less than 20kg; 2.5 mg nebule 3 x 20 minutely
Child greater than 20kg; 5 mg nebule 3 x 20 minutely
Salbutamol
Load 4 mL of undiluted 0.5% Salbutamol solution into nebuliser and top up as required.
Inhalation Continuous nebuliser with a miniumum flow rate of 8 litres per minute
Severe/life-threatening:
Continuous until instructed by Medical Officer
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 40
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Ipratropium Bromide
Child less than 20 kg; 250 micrograms (0.5 mL of 0.025%) solution made up to 4 mL with 0.9% Sodium Chloride
Child greater than 20kg; 500 micrograms (1 mL of 0.025%) solution made up to 4 mL with 0.9% Sodium Chloride
Inhalation
Nebuliser with a minimum oxygen flow rate of 8 litres per minute
Severe/life-threatening
Child less than 20kg; 250 micrograms 3 x 20 minutely
Child greater than 20kg; 500 micrograms 3 x 20 minutely
**Prednisolone 1 mg/kg Oral Stat
Methylprednisolone 1 mg/kg IV/IOStat - severe and life-threatening
(if oral Prednisolone not tolerated)
Hydrocortisone 4 mg/kg IV/IO Stat (one dose only)
*Adrenaline
(If the patient shows signs of asthma associated with anaphylaxis
0.01mL/kg of 1:1,000 IM Stat (if symptoms not reversed Adrenaline may be repeated every five minutes as needed.)
0.9% Sodium Chloride
2mL flush IV/IO As required
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 41
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:1,000 IM
equates to Adrenaline 0.01 mL/kg of 1:1,000 IM
n **Only administer Prednisolone in mild asthma if it
is a prolonged episode or there is a history of severe
asthma.
n For effective salbutamol delivery to the bronchial tree
the oxygen flow rate should be set at 8 litres per
minute
n Methylprednisolone is the preferred IV/IO steroid,
however if Methylprednisolone is unavailable give
IV/IO Hydrocortisone 4 mg/kg stat.
n There is substantial evidence that Ipratropium
Bromide is of limited use in acute episodes of mild
to moderate asthma.
n The use of short acting beta antagonists by
intermittent inhalation via MDI and spacer is now
recommended in the management of acute mild and
moderate asthma.
n Use a nebuliser instead of a MDI if the patient
cannot inhale adequately or requires oxygen.
Salbutamol 2.5 mg or 5 mg nebule can be made up
with 2 mL 0.9% Sodium Chloride.
n The best site for intramuscular (IM) Adrenaline is the
anterolateral aspect of the middle third of the thigh –
the needle needs to be long enough to ensure that
the Adrenaline is injected into the muscle (Soar et al
2008:162).
n For ongoing management refer to NSW Health
PD2012_056 Infants and Children: Acute
Management of Asthma.
ReferencesMIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
NSW Policy Directive PD2012_056 Infants and Children:
Acute Management of Asthma.
National Asthma Council Australia, 2006, Asthma
management handbook. Revised and updated.
National Asthma Council Australia.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
http://www0.health.nsw.gov.au/policies/gl/2012/
GL2012_003.html <accessed 06/03/14>.
Mackway-Jones K. Molyneux E. Phillips B. Wieteska S.
[ED], 2005, Advanced Paediatric Life Support.
The Practical Approach. 4th edn. BMJ Blackwell
Publishing Group Limited, Massachusetts.
Royal Children’s Hospital Melbourne Policy on
Anaphylaxis 2011.
United Bristol Healthcare, Directorate of Children’s
Services, Nebuliser Guidelines 2003. http://www.
bristolpaedresp.org.uk/BCHNebuliserProtocol18.11.2003.
pdf <accessed 17/03/14>.
Soar J, Pumphrey R, Cant A, et al. for the Working
Group of the Resuscitatio Council (UK). 2008.
‘Emergency treatment of anaphylactic reactions:
Guidelines for health care providers’, Resuscitation, vol
77, (2), no. 2.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 42
SECTION 4
If life-threatening activate your local rapid response protocol immediately
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Corresponds with either mild, moderate or severe
scale as described below
n Apnoea
n Inability to maintain own airway
History prompts
n Age less than 12 months
n The following infants are at risk of more serious
disease
– full term infant up to 3 months of age
– premature or low-weight for gestational age
– chronic lung disease
– congenital heart disease
n Parental concern
n Onset
n Associated symptoms
n Relevant past history
n Difficulty feeding
n Fluids in and out past 24 hours
n Allergies
n Immunisation status
Clinical manifestations of acute Bronchiolitis
Mild Moderate Severe
Apnoea No Brief apnoeas Apnoeic episodes
Respiratory distress Minimal or none Moderate – some chest wall recession and nasal flaring
Severe – marked chest wall recession, nasal flaring and/or grunting
Hypoxia in air No Yes Yes, may be difficult to correct with oxygen
Level of Consciousness Alert Alert Increasingly tiring, exhaustion
Fever Fever (greater than 38.50 C present in 50% of infants with bronchiolitis)
Pulse Rate Normal for age Mild Tachycardia Tachycardia or Bradycardia
Document assessment findings, interventions and responses in the patient’s healthcare record
If life-threatening activate your local rapid response protocol immediately
Bronchiolitis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 43
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Ensure nasopharynx clear
Breathing Respiratory rate and effort
SpO2
Mild
Moderate/severe
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Intermittent SpO2 monitoring
Continuous SpO2 monitoring
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Cardiac monitor
Colour
Mild
Moderate
Severe
IV cannulation/IO/ needle insertion/pathology for ‘severe’ bronchiolitis
Monitor vital signs frequently
Continue oral feeding
Continue oral feeding if well tolerated / consider IV fluid therapy
Nil by mouth - IV fluid therapy
Disability AVPU/GCS Monitor LOC frequently
Measure and test
Pathology
Temperature
Fluid input/output
U/A
Collect blood for UEC, FBC, Blood Culture, BGL, Venous blood gas (only if IV inserted)
Fluid balance chart
Ward U/A
Specific treatment
Oxygen therapy
Severe
Apply O2 to maintain SpO2 greater than 94%
Nil by mouth
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 44
Breathing Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
0.9% Sodium Chloride
2 mL flush IV As required
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
Precautions and notesn The child should be assigned to the most severe
grade in which any clinical feature occurs.
n Treatment of fever should be considered in moderate
to severe Bronchiolitis as it may reduce metabolic O2
requirements.
n RSV is a common cause of Bronchiolitis and is very
infectious; precautions should be taken to avoid
cross-infection in particular hand washing.
n For ongoing management refer to NSW Health
PD2012_004 Infants and Children: Acute
Management of Bronchiolitis.
ReferencesNSW Health PD2012_004 Infants and Children: Acute
Management of Bronchiolitis.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Medication standing orders Always check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 45
SECTION 5
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
PAGE 45
Assess for RESPONSE
Open and clear AIRWAY — Position head with chin lift or jaw thrust
Assess BREATHING — Look / Listen / FeelIf patient unresponsive and not breathing normally then GIVE 2 RESCUE BREATHS
Attach monitor/DEFIBRILLATOR as soon as possible ASSESS RHYTHM
Assess CIRCULATION – Commence COMPRESSIONS ifa pulse is not palpable within 10 seconds or less than 60 beats/min
and the patient is unresponsive and not breathing normally.15 compressions : 2 breaths
Compression rate 100 beats/min Compression depth 1/3 of the chest wallHand position: lower half sternum
Paediatric ‘Basic’ Life Support Flow Chart for Healthcare Providers
DR
A
B
C
D
Check for DANGER — Hazards / Risks / Safety
SEND (or call) for helpS
Adapted from the ‘Resus4Kids’ Paediatric Advanced Life Support for Health Care Providers flow charts based on the Australian Resuscitation Council Advanced Life Support for Infants and Children Guideline 12.3 December, 2010
Paediatric Basic Life Support
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 46
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
PAGE 46
Paediatric Cardiorespiratory Arrest
Healthcare Provider CPRCompression to Ventilation Ratio 15 : 2
Minimise interruptions to chest compressions
Immediately recommence
CPR for 2 minutes
Continue CPR for 2 minutes
One DC ShockBiphasic or
Monophasic 4 Joules/kg
Attach Defibrillator – ECG Monitor
Assess Rhythm
During CPR- Ensure high flow oxygen- Establish or verify IV or Intraosseous access- Check electrode / pad positions & contact
CONSIDER AND CORRECT ■ Hypoxaemia■ Hypovolaemia Give IV / Intraosseous fluid Bolus 0.9% Normal Saline 20mL/kg■ Hypo/hyperthermia■ Hypo/hyperkalaemia or other electrolyte disorders■ Tamponade■ Tension pneumothorax■ Toxins / Poisons / Drugs■ Thromboembolism
CONSIDERAdvanced airway (LMA) or prepare for intubation
VassopressorGive Adrenaline 10 micrograms/kg after 2nd shock and then every 2nd cycle (4 minutes) IV / Intraosseous
AntiarrythmicGive Amiodarone 5mg/kg IV / Intraosseous immediately after third shock for VF or VT only
Adrenaline10 micrograms/kgIV / Intraosseous
(0.1mL/kg 1:10 000)Give immediately
then every second cycle (≈ 4 minutes)
NON SHOCKABLEAsystole / PEACompromising
Bradycardia
SHOCKABLE
VF / Pulseless VT
Return of Spontaneous Circulation?Commence post resuscitation care. Follow Recognition of a Sick Child (Page 11)
Adapted from the Australian Resuscitation Council Advanced Life Support for Infants and Children Guideline 12.3 December, 2010
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 47
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
Adrenaline 0.1mL/kg of 1:10,000 per dose IV/IO 4 minutely
Amiodarone5 mg/kg (300 mg maximum dose) diluted/
flushed with 5% GlucoseIV/IO Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 5 mL Flush IV/IO As required
5% Glucose 10-20mL mL Flush IV/IO As required
Precautions and notes.n *Adrenaline 10 micrograms/kg of 1:10,000 IV/IO
equates to Adrenaline 0.1 mL/kg of 1:10,000 IV/IO.
n Minimum requirements for an emergency trolley are
outlined in Appendix 1.
ReferencesAustralian Resuscitation Council, 2010, Any attempt at
resuscitation is better than no attempt Chapter 12.3
Flowchart for the Sequential Management of Life-
Threatening Arrhythmias in Infants and Children http://
www.resus.org.au/policy/guidelines/index.asp <accessed
16/03/14.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 48
SECTION 5
If life-threatening activate your local rapid response protocol immediately
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
If life-threatening activate your local rapid response protocol immediately
Clinical severity prompts
n Corresponds with either mild, moderate or severe
scale as described below
n Representation within 48 hours
History prompts
n Age
n Parental concern
n Onset
n Fluids in and out past 24 hours
n Exposure to anyone else who is sick
n Associated symptoms
n Consider alternative diagnosis if there is; abdominal
distension, bile-stained vomiting, fever greater than
39o C, blood in vomitus or stool, severe abdominal
pain, vomiting in the absence of diarrhoea, headache
n Relevant past history
n Medication history/management at home
Clinical manifestations of acute dehydration
Mild Moderate Severe
Same as no clinical signs
of dehydration plus
Dry mucous
Membranes
Mild Tachycardia
Same as mild plus
Lethargy
Tachycardia
Reduced skin turgor
Sunken eyes
Abnormal respiratory pattern
Same as moderate plus
Poor perfusion –mottled, cool limbs/slow capillary
refill/altered consciousness
Shock - thready peripheral pulses with marked
tachycardia and other signs of poor perfusion
stated above
Source: NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
Gastroenteritis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 49
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Mild
Moderate
(not shocked)
Severe
Pulse – rate/rhythm
Capillary refill
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology - severe dehydration
*Trial of oral fluids 0.5 mL/kg every 5 minutes
*Trial of oral fluids 0.5 mL/kg every 5 minutes
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
U/A (clean catch)
Fluid input/output
Collect blood for UEC, BGL.
Consider FBC
Collect urine for culture and analysis
Fluid balance chart
Specific treatment
Severe dehydration
Signs of shock
To reduce vomiting a one off dose of oral Ondansetron may be considered
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Oral Ondansetron 0.2 mg/kg stat (Single dose, maximum 8 mg)
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 50
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10-15 litres/min Inhalation Continuous
Oral Rehydration Solutions. Eg Gastrolyte, Hydralyte, Pedialyte
0.5 mL/kg Oral Every 5 minutes
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon Hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1mg
IM Stat
Ondansetron 0.2 mg/kg (maximum 8 mg) Oral Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 51
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notesn The child should be assigned to the most severe
grade in which any clinical feature occurs.
n *Oral replacement therapy (fluids) in order of
preference;
– continue breastfeeding – small frequent feeds
– Oral Rehydration Solution (ORS) eg Gastrolyte
or Hydralyte
– 1 part juice or lemonade to 4 parts water (only if
ORS consistently refused and child is not clinically
dehydrated)
n There are no indications for the use of anti-
emetic, anti-motility, anti-diarrhoeal agents in
the management of gastroenteritis in infants and
children, however a one off dose of Ondansetron
(maximum 8 mg) may be considered.
n For ongoing management and fluid regimes refer
to NSW PD2010_009 Infants and Children: Acute
Management of Gastroenteritis.
ReferencesNSW Health PD2010_009 Infants and Children: Acute
Management of Gastroenteritis.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Australian Paediatric Endocrine Group: Clinical Practice
Guidelines: Type One Diabetes in Children and
Adolescents. Canberra, Australia, National Health and
Medical Research Council, 2005.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 52
SECTION 5
If life-threatening activate your local rapid response protocol immediately
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Full PPE measures must be considered
Position Lie supine
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology. If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Clinical severity prompts
n Tachycardia
n Poor brain perfusion
– restlessness
– altered level of consciousness
n Poor skin perfusion
– cold
– pale
– sweaty
– capillary refill greater than 2 seconds
– rash
n Hypotension
History prompts
n Onset
n Events:
– vomiting/diarrhoea
– infection
– gastric/abdominal pain
– UTI (known/suspected)
– pregnancy
– mechanism of injury
– history or evidence of trauma
– poisoning
n Anaphylactic shock must be excluded and is treated
differently
n Poor feeding
n Fever
n Age less than 3 years
n Medication history (child’s and household members)
n Allergies
Shock
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 53
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Blood loss/PV loss
Collect pathology for Blood Culture, venous pH, FBC, UEC, group and hold
Collect urine for culture and analysis
Urine hCG post-menarchal females
Fluid balance chart
Consider In-dwelling catheter and hourly urine measurement
Nil by mouth
Monitor
Specific treatment
Fluid resuscitation IV cannulation/IO needle insertion x 2, pathology.
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Document assessment findings, interventions and responses in the patient’s healthcare record
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 54
Circulatory Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
Precautions and notesn Manage fever to decrease metabolic oxygen demand.
n In Paediatric practice, septicaemia is the commonest
cause of a child presenting in shock, so unless an
alternative diagnosis is very clear (such as trauma,
anaphylaxis or poisoning), collection of blood
sample for culture should be attempted prior to
administration of antibiotics but should not delay treatment.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED], 2005, Advanced Paediatric Life Support. The
Practical Approach. 4th edn. The child in shock, pp
107-109, BMJ Blackwell Publishing Group Limited,
Massachusetts.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Royal Children’s Hospital Melbourne Policy on
Anaphylaxis 2011.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
MIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Australian Paediatric Endocrine Group, Clinical Practice
Guidelines, Type One Diabetes in Children and
Adolescents, Canberra, Australia, National Health and
Medical Research Council, 2005.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 55
SECTION 6
If life-threatening activate your local rapid response protocol immediately
Disabilities Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Full Personal Protective Equipment must be worn at all times
Position
Completely undress and inspect all body surfaces for rash
Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse -rate/rhythm
Capillary refill
Blood pressure
Cardiac monitor
Colour
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Clinical severity prompts
n Appearance of rapidly developing non-blanching
petechial or purpuric rash (bruised haemorrhagic
type/does not blanch ie skin colour does not fade
under pressure) which may be only several lesions
n Associated signs and symptoms include: fever or
hypothermia, cerebral oedema, bulging fontanelle,
high pitched cry, lethargy, irritability, neck stiffness
(greater than 3 years), photophobia (greater than 3
years)
n Seizures
History prompts
n Age less than 3 months
n Parental concern
n Onset
n Associated symptoms:
– altered/abnormal level of consciousness, pallor,
irritability (global signs of meningeal irritation)
n Relevant past history
– contact with someone with meningitis
– head trauma/surgery or infection
– apnoea or history of apnoea
– maternal history Group B streptococcus if less than
3 months old
n Medication history including administration of prior
antibiotics
n Immunisation status
n Allergies
Suspected Bacterial Meningitis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 56
Disabilities Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
DO NOT DELAY ANTIBIOTIC ADMINISTRATION (See Therapeutic Guidelines)
Disability AVPU/GCS + pupils
BGL
Seizures
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Buccal Midazolam 0.3 mg/kg stat (maximum dose of 10mg) and repeat (once only) after 5 minutes if required OR IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Measure and test
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Collect blood for FBC, UEC, BGL, blood cultures
Monitor
Collect urine for culture and analysis
Nil by mouth
Fluid balance chart
Specific treatment
Non-blanching petechial/ purpuric rash or the unwell child with a high index of suspicion for bacterial meningitis
Early administration of steroids to children greater than 3 months who have NOT been pre treated with antibiotics has shown to reduce severe hearing loss by 60%
Urgently contact MO
Urgently administer antibiotics
n 0-3 months IV/IO Ampicillin 50 mg/kg (maximum 2 g) stat or IV/IO Benzyl penicillin 60 mg/kg (maximum 2.4g) stat plus IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat (slow push over 5 - 10 minutes)
n 3 months - 15 years IV/IO Cefotaxime 50 mg/kg (maximum 2 g) stat or IV/IO Ceftriaxone 50mg/kg/dose (maximum 2 g) stat (slow push over 5 - 10 minutes)
*Greater than 3 months IV/IO Dexamethasone 0.15 mg/kg
(maximum 4 mg) stat - immediately prior to the administration of 1st dose of antibiotics
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 57
Disabilities Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochlorideChild less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
Ampicillin 50 mg/kg (maximum 2 g) IV/IO Stat
Benzyl penicillin 60 mg/kg (maximum 2.4 g) IV/IO Stat
Cefotaxime 50 mg/kg (maximum 2 g) IV/IO Stat
Ceftriaxone 50 mg/kg (maximum 2 g) IV/IO Stat
Dexamethasone 0.15 mg/kg (maximum 4 mg) IV/IO Stat
Midazolam0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IOStat and repeat (for seizures) after 5 mins if required (for seizures)
Midazolam 0.3 mg/kg (maximum 10 mg) BuccalStat and repeat (for seizures) after 5 mins if required (for seizures)
0.9% Sodium Chloride. 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 58
Disabilities Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notesn IM antibiotic administration is not preferred in this
setting as supervening shock and hypotension may
lead to failure of absorption of the injected antibiotic.
n The younger the patient, the more subtle the
symptoms and signs and the higher the level of
suspicion.
n Prior antibiotics modify the presentation and
diagnostic yield, and should always be part of the
history.
n For ongoing management refer to the NSW
Health PD2013_044 Infants and Children: Acute
Management of Bacterial Meningitis.
ReferencesNSW Health PD2013_044 Infants and Children: Acute
Management of Bacterial Meningitis.
NSW Health PD 2009_009 Paracetamol Use.
NSW Health PD2009_065 Infants and Children: Acute
Management of Seizures.
Australian Paediatric Endocrine Group, Clinical Practice
Guidelines, Type One Diabetes in Children and
Adolescents, Canberra, Australia, National Health and
Medical Research Council, 2005.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
http://www0.health.nsw.gov.au/policies/gl/2012/
GL2012_003.html <accessed 06/03/14>.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 59
SECTION 7
If life-threatening activate your local rapid response protocol immediately
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Decreased LOC
n Hypotension
n Inability to maintain own airway
n Symptoms suggestive of opiate overdose
– pin-point pupils
– hypoventilation
n Seizures
History prompts
n Time of incident
n Route of exposure
n Type of contaminate/poison/drug
n Amount
n Potentially harmful
n Information (if any) obtained from Poisons
Information Centre
n Reason – accidental/intentional
n Relevant past history
n Potential access to any drugs (including methadone,
illicit drugs, medications, alcohol)
n Associated symptoms
n Medication history
n Allergies
Assessment Intervention
Position Lie supine
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Blood pressure
Capillary refill
Cardiac monitor
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Continuous cardiac monitor if tachycardic or abnormal rhythm
Poisoning
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 60
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
BGL
Possible opiate overdose (characterised by pin point pupils and hypoventilation)
Seizures
Contaminant on skin, eyes, clothing
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient may require endotracheal intubation by a MO to protect the airway from aspiration
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg; 0.5 mg stat; child greater than 25kg; 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
If opiate overdose give IV/IO/IM Naloxone 0.1 mg/kg (maximum 2 mg) repeat as necessary
Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required OR
IM/IV/IO Midazolam 0.15 mg/kg stat (to a maximum dose of 5mg) and repeat (once only) after 5 minutes if required
Remove contaminant (ensure safety of patient and staff member – follow protocols)
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Collect pathology for FBC, UEC, toxicology venous blood gas
Collect urine for drug screen if unexplained symptoms exist
Fluid balance chart
Specific treatment
Presentation within one hour of ingestion (and conscious)
Contact Poisons Information Centre 131 126
Oral/nasogastric Activated charcoal 1 g/kg stat (maximum 50 g)
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 61
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
Midazolam 0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IO Stat and repeat after 5 minutes if required (once only)
Midazolam 0.3 mg/kg (to a maximum dose of 10mg)
BuccalStat and repeat after 5 minutes if required (once only)
Naloxone 0.1 mg/kg (maximum 2 mg) IV/IO/IM Stat Repeat as necessary
Activated charcoal 1 g/kg (maximum 50 g) Oral/nasogastric Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart
as per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement
with the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 62
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notesn Contact Poisons Information 131 126
n Activated charcoal most beneficial if given within
the first hour of ingestion.
n Be alert for acute opiate withdrawal after the
administration of Naloxone. The half-life of Naloxone
is much shorter than the opiate. Repeated doses of
Naloxone may be required.
n If IV/IO access is unavailable, both doses of Naloxone
may be given IM, although it should be noted that
this is not ideal as the IM route will take longer to
take effect.
n All intentional poisoning must be admitted for
assessment no matter how trivial the poisoning
may be.
.
ReferencesPaediatric Emergency Department Poison Protocol http://
www.med.monash.edu.au/paediatrics/resources/poison.
html<accessed 06/03/14>.
Royal Children’s Hospital Melbourne, Acute Poisioning
- Guidelines For Initial Management http://www.rch.
org.au/clinicalguide/guideline_index/Acute_Poisoning_
Guidelines_For_Initial_Management <accessed
13/03/14>.
Mackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED] 2005 Advanced Paediatric Life Support. The
Practical Approach, 4th edn. General approach to
poisoning and envenomation, pp 341-345, BMJ
Blackwell Publishing Group Limited, Massachusetts.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Australian Paediatric Endocrine Group, Clinical Practice
Guidelines, Type One Diabetes in Children and
Adolescents, Canberra, Australia, National Health and
Medical Research Council, 2005.
NSW Health PD2009_065 Infants and Children: Acute
Management of Seizures.
Royal Children’s Hospital Melbourne Paediatric
Pharmacopoeia http://pharmacopoeia.hcn.com.
au/?acc=36422<accessed 06/03/14>.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 63
SECTION 7
If life-threatening activate your local rapid response protocol immediately
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
If life-threatening activate your local rapid response protocol immediately
ALERT: Do not remove pressure immobilisation bandage
Clinical severity prompts
n Neurotoxic paralysis/diplopia/dysphagia
n Convulsions
n Abdominal pain/headache, nausea/vomiting
History prompts
n Events
– time of bite, number of bites, time and type of
first aid applied, pre-hospital treatment, drug/
alcohol intoxication, activity since bite, bite site/
locations
n Associated symptoms:
– weakness, paralysis, headache, nausea, vomiting,
abdominal pain, altered LOC, severe localised pain
(spider bite), localised swelling, diaphoresis, excess
salivation, painful lymph node, ptosis
n Relevant past history/previous envenomation or
antivenom administration
n Medication history
n Allergies
Assessment Intervention
PositionPosition of comfort with carer
Keep patient immobile
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Auscultation
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation First aid
Skin temperature
Pulse – rate/rhythm
Blood pressure
Capillary refill
Cardiac monitor
Apply pressure immobilisation bandage and splinting to all victims of snake and Funnel web spider bite
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient may require endotracheal intubation by a MO to protect the airway from aspiration
(be aware that totally paralysed patients may be fully conscious and will require anaesthesia for intubation)
Snake/Spider Bite
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 64
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Measure and test
Signs of systemic snake envenomation
Pathology
Temperature
U/A
Fluid input/output
Electrocardiography
Whole blood clotting time (in glass tube)
Collect blood for FBC, UEC, Creatinine Kinase, coags, group and hold
Monitor
Check for myoglobin (blood in urine)
Maintain Fluid Balance Chart
12 lead ECG
Specific treatment
Systemic envenomation
Funnel web envenomation
Red back spider envenomation
Anaphylactic reaction to antivenom
Immunisation status
Hydration
MO to consider appropriate antivenom
Antivenom to patients with signs and symptoms: perioral tingling and tongue, twitching, increased sweating, lachrymation, salivation, piloerection, hypertension, nausea ± malaise, dyspnoea – pulmonary oedema, decreased conscious state/coma
Ice to bite site (do NOT apply pressure immobilisation bandage)
Consider Red back spider antivenom
IM *Adrenaline 0.01mL/kg of 1:1,000 stat
Check immunisation status and consider tetanus immunisation requirements when patient stable
Nil By Mouth
Document assessment findings, interventions and responses in the patient’s healthcare record
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
*Adrenaline 0.01mL/kg of 1:1,000 IM Stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 65
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Precautions and notesn *Adrenaline 10 micrograms/kg of 1:1,000 IM
equates to Adrenaline 0.01mL/kg of 1:1,000 IMn Apply pressure immobilisation bandage at the same
pressure as for a sprained ankle.
n A window may be cut in the pressure immobilisation
bandage to obtain a specimen for Venom Detection
Kit analysis.
n Antiserum dose is not based on the patient’s size/
weight but on the amount required to neutralise the
toxin, therefore in general children will receive the
full adult dose.
n IM injections should be avoided (except Boostrix/
ADT booster) in snakebite victims because of
coagulopathy.
n Whole blood clotting test may be performed to
determine the length of time blood takes to clot. It is
performed by placing 5 - 10 mL of venous blood into
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
a glass tube and measuring the time taken for the
blood to clot. Normal time is less than 10 minutes.
n A snake/spider bite observation chart is
recommended for recording vital signs and specific
signs associated with snake and spider bites/
envenomation – (Refer Appendix 6).
n Children who have completed a full primary
immunisation course no greater than 5 years ago will
not require further immunistaion.
n Individuals who have no documented history of
receiving a primary vaccination course (3 doses)
of tetanus toxoid – containing vaccines should
receive a complete primary course. Please refer to
Primary Vaccination in The Australian Immunisation
Handbook 10th Edition 2013.
n IM injections should be avoided in snakebite victims
because of coagulopathy, however consideration
should be given to Tetanus vaccination if required
ReferencesMIMS Online https://www.mimsonline.com.au <accessed
06/03/14>.
Stewart, C. 2003. Snake bite in Australia: First aid and
envenomation management, Accident and Emergency
Nursing Vol 11(2), pp 106-111.
Mackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED] 2005, Advanced Paediatric Life Support, The
Practical Approach. 4th edn. General approach to the
child with poisoning and envenomation pp 341-345,
BMJ Blackwell Publishing Group Limited, Massachusetts.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
http://www.Snakebite & Spiderbite Clinical Management
Guidelines 2007 - NSW<accessed 29.07.2009>.
Cameron, P. Jelinek, G. Everitt, I. Browne, G. Raftos, J.
Text book of Paediatric Emergency Medicine. Elsevier.
2006 pp 527.
NSW Health 2013, GL2014_005 Snake and Spiderbite
Clinical Management Guidelines Third Edition.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 66
Envenomation/Poisoning Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
This page has been left blank intentionally
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 67
SECTION 8
If life-threatening activate your local rapid response protocol immediately
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Refer to the NSW Health Severe Burn Injury Guideline (Appendix 8) Any child meeting this criteria must be transferred to definitive care.
History prompts
n Onset – time of burn
n Events:
– mechanism of injury/exposure
– history of electrical/thermal/chemical/radiation burns
– confined space
– first aid measures - defined
n Associated symptoms:
– cough, hoarse voice, sore throat, sooty sputum,
stridor, neck/facial swelling, singed nasal or facial
hair, confusion
n Relevant past medical history
n Assess for possibility of non accidental injury
n Medication history
n Tetanus immunisation status
n Allergies
The burn surface is cooled with running water 8-25oC
for a minimum of 20 minutes; this is beneficial within the
first three (3) hours only.
Prevent hypothermia and keep the patient warm. If the
patient has suffered chemical burns, ensure staff are
adequately protected from contamination.
Always brush dry chemicals off (use PPE) before applying
cool water.
Clinical severity prompts
n Airway/facial/neck burns
n Burns to hands, feet, perineum
n Electrical burns including lightning injuries
n Chemical burns
n Circumferential burns of limbs or chest
Assessment Intervention
Position Position of comfort with carer/clinical status
Airway Assess patency
Evidence of airway burn;
hoarse voice, stridor, sore throat, sooty sputum, facial swelling
Maintain airway patency
Consider early endotracheal intubation by MO
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask to all patients except those with minor burns
Severe Burns
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 68
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Circulation Skin temperature
Blistering
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac monitor
Constrictive non adhered clothing or jewellery
IV cannulation/IO needle insertion x 2 /pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus PLUS for burns greater than 10% TBSA use Modified Parkland formula for fluid replacement (Appendix 8)
Continuous cardiorespiratory monitor (especially for electrical burns and lightning strikes)
Monitor vital signs frequently
Remove
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
Measure and test
Primary survey
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Secondary survey
Pathology
Temperature
U/A
Fluid input/output
Assess TBSA
Burns greater than 10% TBSA
Repeat
Oral Paracetamol 15 mg/kg stat. Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral liquid Oxycodone 0.1mg/kg (maximum 5mg) stat
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10mg) OR if child greater than 10kg consider Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms total dose)
Non pharmacological measures must be considered early – supportive and distractive techniques Commence
Collect blood for FBC, UEC, BGL, (consider group and hold, myoglobin, ABG/venous blood gas)
Avoid hypothermia
Ward U/A
Monitor – maintain UO at 2 mL/kg/hour Fluid balance chart
Calculate total body surface area burnt
Use paediatric burns assessment chart
Nil orally if burns TBSA greater than 10-15%
For burns greater than 10% TBSA, consider indwelling catheter to measure and record urine output every hour
Modified Parkland formula (see appendix 8): in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmann’s) solution 4mL x kg body weight x % TBSA burnt. Give 50% of total amount first 8 hours from time of burn; give the remaining 50% over the next 16 hours
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 69
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Specific treatment
Liquid chemical
Powder chemical
Electrical/lightning strike
Circumferential burns
Burn wounds
Gastrointestinal care
Immunisation status
Copious water irrigation
Brush off prior to copious water irrigation. Staff must use Personal Protective Equipment
Maintain UO greater than 2 mL/kg/hour
Elevate the affected limb above the level of the heart. Perform neurovascular observations every 15 minutes
If transferring within 8 hours wrap the burns with cling wrap. If the face is burnt paraffin ointment should be applied
If there is a delay in transfer wound management should be in consultation with the burn surgeon who will receive the patient or with NETS. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary burns service and do not apply to the face
Patients with major burns must remain nil by mouth until after consultation with the appropriate burns unit
Check immunisation status and consider tetanus immunisation requirements when patient stable
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 70
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Paracetamol
Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours)
Dose is recommended for patients of normal or average build.*
15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral Stat
Oxycodone 0.1 mg/kg (maximum 5 mg) Oral Stat
Fentanyl1.5 microgram/kg (maximum 75 micrograms total dose)
Intranasal5 minutely (titrated to pain and sedation)
Morphine sulphate 0.1 mg/kg IV/IO Stat
Compound Sodium Lactate
(Hartmann’s) solutionAs per Modified Parkland formula IV/IO As per formula
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
* Refer to NSW Health PD2009_009 Paracetamol Use for other patients
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 71
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as
possible. At the time of this review, the Medical
Officer must check and countersign the nurse’s
record of administration on the medication chart as
per NSW Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Precautions and notesn Consult with burns specialist (or NETS) early.
n Children have different body surface area
proportions: Use the Paediatric Rule of Nines, and adjust for age by taking 1% BSA from the
head and adding ½% BSA to each leg for each year
of life after 1 year until 10 years.(Adult proportions
are reached at 10Yrs.) (Refer to Appendix 8)
n For ongoing fluid management in children,
maintenance fluids should be added to the fluid
calculated with the Modified Parkland Formula.
n Do not use ice to cool burn.
n Be cautious in administration of Morphine if there
is an altered level of consciousness, respiratory
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
compromise or hypotension. Use of sedation
scores may be beneficial in reassessment.
n Refer to burn injury Referral/Retrieval Criteria Checklist; Burns Transfer Flow Chart; Burn Patient Emergency Assessment and Management Chart; Assessment of Total Body Surface Area (TBSA) and Burn Distribution; Resuscitation Fluids (Refer Appendix 8)
n Children who have completed a full primary
immunisation course no greater than 5 years ago will
not require further immunisation.
n Individuals who have no documented history of
receiving a primary vaccination course (3 doses)
of tetanus toxoid – containing vaccines should
receive a complete primary course. Please refer to
Primary Vaccination in The Australian Immunisation
Handbook 11th Edition January 14.
ReferencesMackway-Jones K. Molyneux E. Phillips B. Wieteska
S. [ED] 2005, Advanced Paediatric Life Support, The
Practical Approach. 4th edn. The burned or scalded child,
pp 199-204 BMJ Blackwell Publishing Group Limited,
Massachusetts.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
http://www0.health.nsw.gov.au/policies/gl/2012/
GL2012_003.html <accessed 06/03/14>.
NSW Health PD2009_009 Paracetamol Use <accessed
06/03/14>.
NSW Health Guideline GL2008_012 Burn Transfer
Guidelines - NSW Severe Burn Injury Service - 2nd
Edition http://www0.health.nsw.gov.au/policies/gl/2008/
GL2008_012.html <accessed 06/03/14>.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 72
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
This page has been left blank intentionally
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 73
SECTION 8
If life-threatening activate your local rapid response protocol immediately
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Altered level of consciousness
n Wheezing
n Crepitations
n Pink frothy sputum
n Tachycardia
n Respiratory or cardiac arrest
History prompts
n In diving accidents or the unconscious submersion
victim, spinal and skull fractures must be considered
n Consider
– the possibility of associated drug and or alcohol
use
– attempted self harm
– syncope or seizure as a precipitating event
– circulatory arrest
n Hyperventilation before breath holding underwater
n Duration of immersion
n Water temperature
n Time of accident, time of rescue, time of first
effective CPR
n History or evidence of traumas
Assessment Intervention
Position
Sit upright depending on clinical condition
Position of comfort with carer
Position supine if C – spine injury is suspected
Airway Assess patency Maintain airway patency
If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration
Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Drowning
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 74
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Breathing Respiratory rate and effort
SpO2
Wheeze
If patient cannot inhale adequately to use an MDI and spacer and requires oxygen
Auscultation
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
If SpO2 falls below 94% with O2 consult MO
If wheeze present give inhaled Salbutamol:
Child less than 20kg; 6 puffs Salbutamol 100 micrograms MDI + spacer stat; Child greater than 20kg; 12 puffs Salbutamol 100 micrograms MDI + spacer stat
Child less than 20kg; 2.5 mg Salbutamol nebule stat;
Child greater than 20kg; 5 mg Salbutamol nebule stat. Give via nebuliser mask at a minimum oxygen flow rate of 8 litres/min
Consider risk of pneumothorax, especially if rapid ascent from a significant depth
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac Monitor
Colour
Remove wet clothing – cover with blankets, (passive warming). Do NOT actively rewarm unless < 34°C
IV cannulation/IO needle insertion /pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS + pupils
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Measure and test
Pathology
Temperature
U/A
Fluid input/output
Chest x-ray
Collect blood for FBC, UEC, serum glucose, ABG/venous blood gas if available.
Avoid hypothermia
Core temperature if possible
Fluid balance chart
Nil by mouth
Consider In-dwelling catheter and hourly measures
If available
Specific treatment
Gastric distension No attempt should be made to empty the stomach by external pressure. Consider gastric decompression with an oro or nasogastric tube
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 75
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon Hydrochloride
Child less than 25kg 0.5 mg
Child greater than 25kg 1 mgIM Stat
Salbutamol
Child less than 20kg; 6 puffs of 100 microgram dose = (600 micrograms)
Child greater than 20kg; 12 puffs of 100 microgram dose = (1200 micrograms)
Inhalation
MDI + Spacer
Child less than 20kg; 6 puffs stat
Child greater than 20kg; 12 puffs stat
Salbutamol
Child less than 20kg; 2.5 mg nebule
Child greater than 20kg; 5 mg nebule
Inhalation Nebuliser with a minimum oxygen flow rate of 8 litres per minute
Child less than 20kg; 2.5 mg nebule stat
Child greater than 20kg; 5 mg nebule stat
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 76
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Precautions and notesn The new definition of drowning includes both cases
of fatal and nonfatal drowning. ‘Drowning is the
process of experiencing respiratory impairment
from submersion/immersion in liquid’ (WHO
2005). Drowning outcomes are classified as death,
morbidity. WHO states that the terms wet, dry,
active, passive silent and secondary drowning
should no longer be used (WHO 2005). Therefore a
simple, comprehensive, and internationally accepted
definition of drowning has been developed.
n Hypothermia makes assessment of the circulation
difficult.
n Resuscitation attempts should continue even after
prolonged immersion.
ReferencesAdvanced Life Support Group, Advanced Paediatric
Life Support Australia and New Zealand, The Practical
Approach 5th edn.
Royal Children’s Hospital Melbourne, Clinical Practice
Guideline, Near Drowning http://www.rch.org.au/
clinicalguide/guideline_index/Near_Drowning <accessed
13/03/14>
ILCOR Advisory Statements, 2003, Recommended
Guidelines for Uniform Reporting of Data from
Drowning, The “Utstein Style.” [Online] Available: http://
circ.ahajournals.org/content/108/20/2565.full <accessed
06/03/14>.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1 http://www0.health.
nsw.gov.au/policies/gl/2012/GL2012_003.html.
Ward M. RNSH Emergency Department Guideline,
Emergency Department Presentations with Associated
Hypothermia.
Zuckerbraun N.S and Saladino R.A 2005, Paediatric
Drowning, current management strategies for immediate
care Clinical Practice Emergency Medicine 6(1) pp 49-56.
Australasian Paediatric Endocrine Group National
Evidence-Based Clinical Care Guidelines for Type 1
Diabetes for Children, Adolescents and Adults 2011
http://www.apeg.org.au/Portals/0/guidelines1.pdf
<accessed 17/03/14>.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
World Health Organization (WHO), Department
of Injuries and Violence Prevention World Health
Organisation, 2003, Facts about injuries: Drowning
http://www.who.int/violence_injury_prevention/
publications/other_injury/en/drowning_factsheet.
pdf?ua=1 <accessed 06/03/2014>.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 77
SECTION 8
If life-threatening activate your local rapid response protocol immediately
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Modified paediatric Glasgow Coma Score less than
14
n Correspond with either low risk, intermediate risk,
high risk scale (Refer Appendix 9)
n Loss of consciousness with a history of trauma
n Visible deformities (fracture of skull or facial bones)
n Ecchymosis around eyes or ears
n CSF leak from nose or ears
n Inequality or non-reactivity of pupil/s
n Age less than 1year regardless of signs and symptoms
n Seizure greater than1hour post injury
n Suspected fracture of skull (boggy haematoma)
n Known/suspected C-spine injury
n Full or bulging fontanelle
History prompts
n Events–high risk mechanism of injury
n Associated symptoms:
– headache, confusion, irritability, memory loss,
nausea, vomiting, dizziness, speech, motor and/or
visual disturbances, seizure, persisting drowsiness,
lethargy, irritability, headache or behaviour change
n Relevant past history
n Medication history
n Allergies
n Immunisation status
n Consider non-accidental injury
Assessment Intervention
PositionPosition head up 30o unless contraindicated
Position of comfort with carer
Airway Assess patency Maintain airway patency
Stabilise the C-spine with in-line immobilisation
(if there is a possibility of injury)
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Blood pressure
Capillary refill
Cardiac monitor
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
15 minutely for high risk category patients
Monitor vital signs frequently
Continuous monitoring for high risk category patients
Head Injury
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 78
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Disability AVPU/GCS + pupils
Low risk
Intermediate risk
High risk
Severe head injury (GCS less than 9)
BGL
Seizures
Monitor LOC frequently
If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration.
Consider oro-pharyngeal airway, airway opening manoeuvres and bag –valve mask to assist ventilation
May be discharged after medical review. Hourly observations until discharge.
Half hourly observations for 4-6 hours until GCS 15 is sustained for 2 hours, then hourly observations until discharge
Consider transfer
CT scan if acute deterioration or persisting symptoms (Refer Appendix 9)
Continuous cardiorespiratory and oxygen saturation monitoring
BP and GCS every 15-30 minutes
Urgent CT
Transfer/retrieval
Trauma call-retrieval to nearest paediatric referral centre
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; 0.5 mg stat for a child less than 25kg; IM Glucagon 1 mg stat for a child greater than 25kg
Monitor finger prick BGL every 15 minutes until within normal limits
Buccal Midazolam 0.3 mg/kg (maximum dose 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required
Measure and test
Pathology
Primary survey
Secondary survey
Neurological observations
Temperature
U/A
Fluid input/output
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Collect blood for FBC, UEC (consider drug/alcohol blood levels)
Repeat
Commence
Monitor frequently
Protect from hypo/hyperthermia
Test for presence of blood
Fluid balance chart
Nil by mouth if decreasing level of consciousness
GCS 14 or 15 and patient not nil by mouth
Oral Paracetamol 15 mg/kg stat Single dose never to exceed 1gm and no more than 4gms in 24 hours.Oral liquid Oxycodone 0.1 mg/kg (maximum dose 5mg)
IV/IO Morphine 0.1 mg/kg (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal **Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) (maximum 75 micrograms/kg)
Non pharmacological measures must be considered early-supportive and distractive techniques
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 79
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Paracetamol
Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours).
Dose is recommended for patients of normal or average build.*15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral Stat
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
Midazolam 0.15 mg/kg (to a maximum dose of 5mg)
IM/IV/IOStat and repeat (once only) after 5 minutes if required
Midazolam 0.3 mg/kg (to a maximum dose of 10mg)
BuccalStat and repeat (once only) after 5 minutes if required
Oxycodone 0.1 mg/kg (maximum 5 mg) Oral Stat
**Fentanyl1.5 microgram/kg (maximum 75 micrograms total dose)
Intranasal5 minutely (titrated to pain and sedation)
Morphine sulphate 0.1 mg/kg IV/IOStat.(repeat once in 10 minutes if necessary to a maximum dose of 10 mg)
Assessment Intervention
Specific treatment
Severe High risk
Severe head injury
Seizures
Refer for urgent CT
Trauma call
Buccal Midazolam 0.3 mg/kg (to a maximum dose of 10mg) stat and repeat (once only) after 5 minutes if required ORIM/IV/IO Midazolam 0.15mg/kg (to a maximum dose of 5mg) stat and repeat (once only) after 5 minutes if required
Document assessment findings, interventions and responses in the patient’s healthcare record
* Refer to NSW Health PD2009_009 Paracetamol Use for other patients
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 80
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Drug Dose Route Frequency
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
Precautions and notesn **Intranasal Fentanyl is contraindicated in
children where a base of skull fracture is suspected or if bleeding nose
n If blood or fluid is draining from the nose or ear
suspect a fractured base of skull.
n Do NOT insert nasopharyngeal airway or nasogastric
tube in a patient suspected of having a fractured base
of skull or nasal bone fracture.
n The provision of opioid analgesia is not
contraindicated once the life-saving surgical and
neurological evaluation has been performed.
n Be cautious administering Morphine or Fentanyl if
there is an altered level of consciousness, respiratory
compromise or signs of shock. Use of sedation scores
may be beneficial in this reassessment.
n A scalp laceration or intracranial bleed can result in
significant blood loss in infants and toddlers.
n For explanation of head injury risk categories (Refer
Appendix 9)
n If suspected non-accidental injury refer to the NSW
Health PD2011_024 Infants and Children: Acute
Management of Head Injury.
n For ongoing head injury management refer to the
NSW Health PD2011_024 Infants and Children: Acute
Management of Head Injury.
ReferencesNSW Health PD2011_024 Infants and Children: Acute
Management of Head Injury.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 81
Trauma Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
NSW Health GL2012_003 Rural Adult Emergency Clinical
Guidelines 3rd Edition Version 3.1.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
NSW Health PD2009_009 Paracetamol Use <accessed
06/03/14>
National Institute for Health and Care Excellence 2014
Guideline, Head injury: Triage, assessment, investigation
and early management of head injury in children, young
people and adults http://publications.nice.org.uk/head-
injury-cg176<accessed 06/03/14>.
Royal Children’s Hospital Melbourne 2012 Sucrose (oral)
for procedural pain management in infants http://www.
rch.org.au/rchcpg/hospital_clinical_guideline_index/
Sucrose_oral_for_procedural_pain_management_in_
infants/<accessed 06/03/14>.
Dunning, J., Patrick Daly, J., Lomas, J-P., Lecky, F.,
Batchelor, J., Mackway-Jones, K. Derivation of the
children’s head injury algorithm for the prediction of
important clinical events decision rule for head injury in
children. Archives of Disease in Childhood 2006;91:885-
891.
Minor head trauma in infants and children: Evaluation.
http://www.uptodate.com/contents/minor-head-trauma-
in-infants-and-children-evaluation?source=sear&selected
Title=26%7E143. <accessed 03//04/14>
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 82
SECTION 9
If life-threatening activate your local rapid response protocol immediately
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Clinical severity prompts
n Signs of shock
n Bile stained vomiting
n Bloody stool
n Distension
n Localised tenderness to right upper or lower quadrant
of abdomen
n Inguinoscrotal pain or swelling
n Rapid onset
History prompts
n Nature of onset
n Parental concern
n Associated symptoms
– nature of pain/radiation
– nausea, vomiting
– diarrhoea
– last menstrual period/symptoms of pregnancy
– urinary symptoms
– weight loss
n Relevant past history
n Immunocompromised
n Medication history
n Events – mechanism of injury (if trauma involved)
n Allergies
n Immunisation status
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Colour
IV cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, give IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS
BGL
Monitor LOC frequently
Finger prick BGL
If less than 3.5 mmol/L administer IV/IO 10% Glucose at 2.5 mL/kg stat. If no IV/IO access available administer IM Glucagon; child less than 25kg 0.5 mg stat; child greater than 25kg 1 mg stat
Monitor finger prick BGL every 15 minutes until within normal limits
Abdominal Pain
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 83
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Measure and test
Abdominal assessment
Pain score (1-3)
Pain score (4-6)
Pain score (7-10)
Pathology
Temperature
U/A (clean catch)
Fluid input/output
Look, listen feel
Oral Paracetamol 15 mg/kg stat if not nil by mouth.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral liquid Oxycodone 0.1 mg/kg (max dose 5mg)
IV/IO Morphine 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10 mg) OR Intranasal Fentanyl 1.5 microgram/kg 5 minutely (titrated to pain and sedation) 75 micrograms total dose
Non pharmacological measures must be considered early – supportive and distractive techniques
Collect blood for FBC, UEC, (consider LFT’s, amylase, coags, group and hold)
Collect urine for culture and analysis, Urine hCG
Fluid balance chart
Specific treatment
Hydration/input
Nausea and vomiting
Nil by mouth
Record and report - fluid balance chart
Document assessment findings, interventions and responses in the patient’s healthcare record
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 84
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
Paracetamol
Precaution: Prior to administration determine recent administration of any medicines containing Paracetamol (minimum dosing interval is 4 hours).
Dose is recommended for patients of normal or average build.*
15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Oral Stat
10% Glucose 2.5 mL/kg IV/IO Stat
Glucagon hydrochloride Child less than 25kg; 0.5 mg Child greater than 25kg; 1 mg
IM Stat
Oral liquid Oxycodone 0.1mg/kg (max 5mg) Oral Stat
Fentanyl1.5 microgram/kg (maximum 75 microgram total dose)
Intranasal5 minutely (titrated to pain and sedation)
Morphine sulphate 0.1 mg/kg IV/IOStat.(repeat once in 10 minutes if necessary to a maximum dose of 10 mg)
0.9% Sodium Chloride 20 mL/kg IV/IO Bolus
0.9% Sodium Chloride 2 mL flush IV/IO As required
* Refer to NSW Health PD2009_009 Paracetamol Use for other patients
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 85
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement
with the management and care of the patient.
Precautions and notesn Early administration of Morphine Sulphate in patients
with acute abdominal pain does not reduce the
detection rate of serious pathology but may actually
facilitate it.
n Redcurrant jelly stool is suggestive of intussusception
which is a surgical emergency.
n For ongoing management refer to NSW Health
PD2013_053 Infants and Children: Acute
Management of Abdominal Pain.
ReferencesNSW Health PD2013_053 Infants and Children: Acute
Management of Abdominal Pain.
NSW Health PD2009_009 Paracetamol Use <accessed
06/03/14>.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Australian Paediatric Endocrine Group, Clinical Practice
Guidelines, Type One Diabetes in Children and
Adolescents, Canberra, Australia, National Health and
Medical Research Council, 2005.
Royal Children’s Hospital Melbourne 2012 Sucrose (oral)
for procedural pain management in infants http://www.
rch.org.au/rchcpg/hospital_clinical_guideline_index/
Sucrose_oral_for_procedural_pain_management_in_
infants/<accessed 06/03/14>.
Australian Resuscitation Council, Guideline 12.4,
Medications & Fluids in Paediatric Advanced Life
Support; December 2010.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 86
SECTION 9
If life-threatening activate your local rapid response protocol immediately
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Assessment Intervention
Position Position of comfort with carer
Airway Assess patency Maintain airway patency
Breathing Respiratory rate and effort
SpO2
Assist ventilation if required
Apply O2 to maintain SpO2 greater than 94%
Apply high flow O2 (10-15 litres/min) via a paediatric non-rebreather mask
Circulation Skin temperature
Pulse – rate/rhythm
Capillary refill
Blood pressure
Cardiac Monitor
Colour
Access CVAD/IV Cannulation/IO needle insertion/pathology
If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, give CVAD/IV/IO 0.9% Sodium Chloride 20 mL/kg bolus
Monitor vital signs frequently
Disability AVPU/GCS
BGL
Monitor LOC frequently
Finger prick BGL
Measure and test
Pathology
Temperature
U/A (Clean catch)
Fluid input/output
Collect blood for FBC, UEC, Blood Cultures, group and hold
Per axilla (do not take rectal temperatures in
Haematology/Oncology patients)
Collect urine for culture and analysis
Fluid balance chart
Specific treatment
Contact Paediatrician/Oncologist as soon as practicable.
Anticipate antibiotics as indicated in patients journal or febrile neutropenia guideline. Plan for administration of IV Antibiotics within 30 minutes.
Document assessment findings, interventions and responses in the patient’s healthcare record
Clinical severity prompts
n Haematology/Oncology patient presents with fever during treatment or ceased treatment within the last 3 months
n Aplastic anaemia or chronic neutropenian CVAD insitun Received chemotherapy within the last 6 weeks n Absolute neutrophil count less than 1.0x109/L
within the last 7 days n Hodgkin’s disease n Less than12months of agen Clinical presentation suggestive of shock
History prompts
n Recipients of bone marrow transplant in the last
12 months
n A single axillary temperature greater than or
equal to 38.50C or a temperature greater than or
equal to 380C on at least 2 occasions 1 hour apart
within a 12 hour period
n Medical history
n Treatment history
n See patient journal
n Parental concern
Febrile Neutropenia
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 87
Other Emergencies Medical Officer must be notified immediately For paediatrics only
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Paediatric Advanced Clinical Nurses.
Medication standing ordersAlways check for allergies and contraindications.
The weight of a child is mandatory for calculating drug and fluid doses prior to administration
Drug Dose Route Frequency
Oxygen 10 -15 litres/min Inhalation Continuous
0.9% Sodium Chloride 20 mL/kg CVAD/IV/IO Bolus
0.9% Sodium Chloride 2 mL flush CVAD/IV/IO As required
Medications within this guideline must be administered within the context of the formulary.n Medical Officer review is required as soon as possible.
At the time of this review, the Medical Officer
must check and countersign the nurse’s record of
administration on the medication chart as per NSW
Health PD2013_043.
n If a Paediatric Advanced Clinical Nurse uses these
clinical guidelines, a Medical Officer will be notified
immediately to ensure their early involvement with
the management and care of the patient.
Precautions and notesn Administration of antibiotics within 30 minutes
is the gold standard. Urgent consultation with the treating oncology team must occur
n Child must be assessed within 15 minutes of
presentation to ED or onset of fever in the inpatient
setting.
n Child must be nursed in protective isolation.
n Fever is a common occurrence with multiple causes.
In the febrile Haematology/ Oncology patient
consider infection until proven otherwise.
n Neutropenic hosts have a decreased ability to
manifest an inflammatory response: signs and
symptoms may be subtle. Absence of fever in cancer
patients with localising signs does not mean that the
infection is controlled or insignificant.
n Do not wait 1 hour for topical local anaesthetic to
work in the febrile neutropenic child.
ReferencesSydney Children’s Hospital 2008 Clinical Standards
Practice Manual 2008, Centre for Children’s Cancer and
Blood disorders, Clinical Guidelines for the management
of the febrile Haematology/oncology patients.
MIMS Australia 2013. MIMS Annual 37th edn. St
Leonards.
Authorising Medical Officer signature:
Name:
Designation:
Date:
Drug Committee approval:
Date:
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 88
Activated Charcoal.......................................................89Adrenaline ...................................................................90Amiodarone Hydrochloride ..........................................91Ampicillin sodium ........................................................92Benzylpenicillin sodium ................................................93Budesonide (Pulmicort) ................................................94Ceftriaxone Sodium .....................................................95Cefotaxime Sodium .....................................................96Compound Sodium Lactate (Hartmann’s Solution) .......97Dexamethasone ...........................................................98Fentanyl .......................................................................99Glucagon Hydrochloride ............................................10010% Glucose .............................................................102Hydrocortisone sodium succinate (Solu-Cortef) ..........104Ipratropium Bromide (Atrovent) .................................105Midazolam hydrochloride...........................................106Morphine sulphate. ...................................................107Naloxone ...................................................................108Ondansetron ..............................................................109Oxycodone ................................................................110Paracetamol (oral) ......................................................111Prednisolone ..............................................................113Salbutamol sulphate (Ventolin) ...................................1140.9% Sodium Chloride ..............................................116
Formulary index
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 89
Activated charcoalDrug category: Detoxifying agents, antidotes
Drug Name Activated Charcoal
Indications/DosesPoisoning
1 g/kg oro/nasogastric stat (maximum 50 g)
Contraindications
Poisoning with; strong acid, alkali, Iron sulfate, other Iron salts, cyanides, sulfonylureas including tolbutamide, malathion, dicophane (clofenotane), Li, ethanol, methanol, ethylene glycol, hydrocarbons, lithium, iron compounds, potassium and other metallic ions, fluoride, hydrocarbons.
Unprotected airway. Decreased LOC, GI tract not intact, significant fluid, electrolyte abnormalities. Do not give repeat doses or to infants less than 1 year.
Interactions Oral medications
Pregnancy
Activated charcoal is not absorbed from the gastrointestinal tract and is not expected to pose a risk to the fetus during pregnancy. However, the cathartic effect of sorbitol may cause diarrhoea resulting in electrolyte disturbances or dehydration. Should be used during pregnancy only when necessary. The potential risk to the fetus of both the poisoning and the treatment need to be balanced against the risk of failing to detoxify the mother.
PrecautionsCentral Nervous System depression, GIT disturbances and recent surgery, children 1 to 11 years, diarrhoea may lead to electrolyte disturbance
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fifth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 90
AdrenalineDrug Category: Parenteral adrenergic agents
Drug Name Adrenaline
Indications/Doses Anaphylactic reaction 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.
Asthma 0.01mL/kg 1:1,000 IM Stat. If symptoms not reversed, Adrenaline may be given every 5 minutes as needed.
Cardiorespiratory Arrest (Advanced Life Support) 0.1mL/kg of 1:10,000 IV/IO every 4 minutes
Croup 0.5 mL/kg (undiluted) nebulised 1:1,000 to a maximum of 5 mL
Contraindications
Interactions
Sympathomimetics cause additive effects. Beta blockers antagonise therapeutic effects of Adrenaline; digitalis potentiates proarrhythmic effects of Adrenaline; tricyclic antidepressants; Monoamine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline; phenothiazine causes a paradoxical decrease in blood pressure.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed. Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus.
Precautions
Adverse effects include cardiac ischaemia or dysrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid haemorrhage; use with caution in hypertension, cardiovascular disease, and cerebrovascular insufficiency; phenothiazines can cause a paradoxical decrease in blood pressure comment as above
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fifth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_053 Infants and Children: Acute Management of Croup
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 91
Amiodarone HydrochlorideDrug Category: Antiarrhythmics
Drug Name Amiodarone Hydrochloride
Indications/DosesCardiorespiratory Arrest (Advanced Life Support)
5 mg/kg/dose IV/IO (maximum 300 mg/dose) stat (Dilute with 5%Glucose)
ContraindicationsDocumented history of hypersensitivity; systemic lupus erythematosus, digitalis induced dysrhythmias, torsade de pointes, second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome.
Interactions
Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecanide, digoxin, cyclosporine, beta-blockers and anti coagulants; and disopyramide increases cardiotoxicity; co-administration with calcium channel blockers may cause additive effects, further decreasing myocardial contractility; cimetidine may increase amiodarone levels.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Avoid use 3 months before and during pregnancy; may cause thyroid dysfunction and bradycardia in the fetus.
PrecautionsHypotension (most common adverse effect), bradycardia, and Atrio-Ventricular block may occur. Phlebitis is an issue. Incompatible with 0.9% Sodium Chloride. Overly rapid administration can cause hypotension.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 92
Ampicillin sodiumDrug Category: Antibiotic
Drug Name Ampicillin sodium
Indications/DosesSuspected Bacterial Meningitis
Infants 0-3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose infuse slowly.
Contraindications History of hypersensitivity to beta-lactam antibiotics
Interactions Gentamicin
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 93
Benzylpenicillin sodiumDrug Category: Antibiotic
Drug Name Benzylpenicillin sodium
Indications/DosesSuspected Bacterial Meningitis
Infants 0-3 months old 60 mg/kg IV/IO stat (maximum 2.4 g) per dose infuse slowly.
Contraindications History of hypersensitivity reactions to beta-lactam antibiotics.
Interactions
Intravenous solutions of benzylpenicillin are physically incompatible with many other substances including certain antihistamines, some other antibiotics, metaraminol tartrate, noradrenaline acid tartrate, thiopentone sodium and phenytoin sodium, may effect glucose in urinalysis
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsSerious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 94
Budesonide (Pulmicort)Drug Category: Corticosteroids
Drug Name Budesonide (Pulmicort)
Indications/DosesCroup
2 mgs (1mg/2mL nebules) undiluted nebulised stat
Contraindications Known history of hypersensitivity to Budesonide
Interactions Ketoconazole and Itraconazole can increase systemic exposure to budesonide. This is of limited clinical importance for short-term (one to two weeks) treatment with CYP3A inhibitors, but should be taken into consideration during long-term treatment.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
PrecautionsBudesonide is not indicated for rapid relief of bronchospasm. Pulmicort is, therefore, not suitable as sole therapy for the treatment of status asthmaticus or other acute exacerbations of asthma where intensive measures are required.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_053 Infants and Children: Acute Management of Croup
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 95
Ceftriaxone SodiumDrug Category: Antibiotic
Drug Name Ceftriaxone Sodium
Indications/DosesSuspected Bacterial meningitis
Children greater than 3 months old 50 mg/kg IV/IO stat (maximum 2 g) per dose
Contraindications Allergy to the cephalosporins
Interactions Chloramphenicol. Ceftriaxone is incompatible with calcium; do not give via calcium containing solutions i.e do not mix with Hartmann’s
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals [1] have not shown evidence of an increased occurrence of fetal damage.
PrecautionsRenal, hepatic impairment; vitamin K synthesis; prolonged use; history of GI disease (esp colitis); pregnancy; lactation
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 96
Cefotaxime SodiumDrug Name Cefotaxime Sodium
Indications/DosesSuspected Bacterial meningitis
50 mg/kg IV/IO stat (maximum 2 g) per dose (slow push over 5-10 minutes).
Contraindications Known hypersensitivity to Cefotaxime or other cephalosporin antibiotics.
Interactions Gentamicin
Pregnancy
Category B1 Drugs that have been taken by only a limited number of pregnant women and women of
childbearing age, without an increase in the frequency of malformation or other direct or
indirect harmful effects on the human fetus having been observed. Studies in animals [1]
have not shown evidence of an increased occurrence of fetal damage.
Precautions Arrhythmia.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 97
Compound Sodium Lactate (Hartmann’s Solution)Drug Category: Intravenous Fluids
Drug Name Compound Sodium Lactate (Hartmann’s Solution)
Indications/DosesBurns
IV/IO as per Parkland formula
ContraindicationsClinical states adversely affected by sodium, severe impairment of renal function, lactic acidosis, congestive cardiac failure
Interactions Administration via the same line as blood products may lead to coagulation. Concomitant administration with potassium sparing diuretics and angiotensin (ACE inhibitors) may cause severe hyperkalaemia.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
Precautions Sodium retention, Pregnancy, Corticosteroids.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 98
DexamethasoneDrug Category: Systemic Corticosteroids
Drug Name Dexamethasone
Indications/Doses Croup 0.3 mg/kg oral stat
Suspected Bacterial Meningitis in children greater than 3 months of age0.15 mg/kg IV/IO stat
Contraindications Uncontrolled infections. Known hypersensitivity to dexamethasone
Interactions Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Oral contraception.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed
Precautions Live vaccines, cirrhosis or hypothyroidism may enhance the effect of corticosteriods
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2010_053 Infants and Children: Acute Management of Croup
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 99
FentanylDrug Name Fentanyl
Indications/Doses Recognition of a sick child 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)
Burns 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)
Head injury 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)
Abdominal pain 1.5 microgram/kg intranasal stat (maximum 75 micrograms total dose)
Contraindications
Known hypersensitivity to opioid analgesics. CNS depression. Raised intra cranial pressure,
concomitant monoamine oxidase inhibitors. Children less than 1 year. Bleeding from the
nose.
Interactions CNS depressants. Monoamine oxidase inhibitors
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of
causing harmful effects on the human fetus or neonate without causing malformations.
These effects may be reversible.
Precautions Respiratory depression, impaired renal or hepatic function
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition
http://aidh.hcn.com.au/index.php <accessed 06/03/14>
Bezzina, A. 2006. Intranasal Medication Administration Guidelines: Use of Mucosal Atomiser Device.
Wollongong Hospital, Wollongong.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 100
Glucagon HydrochlorideDrug Category: Glucose-elevating Agents
Drug Name Glucagon Hydrochloride
Indications/DosesRecognition of the Sick Baby and ChildIf IV access unavailable:n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/Ln Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
SeizuresIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Unconscious patient If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Gastroenteritis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Shock If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Suspected bacterial meningitis If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
PoisoningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
DrowningIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Head injuryIf IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Abdominal pain If IV access unavailable: n Children greater than 25kg; 1mg IM stat if BGL less than 3.5 mmol/L n Children less than 25kg; 0.5 mg IM stat if BGL less than 3.5 mmol/L
Contraindications Documented hypersensitivity, Phaeochromocytoma, insulinoma, glucagonoma
Interactions May enhance the effects of anticoagulants
Pregnancy
Category B2
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals[1] are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 101
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain
NSW Health PD2009_065 Infants and Children: Acute Management of Seizures
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
Drug Name Glucagon Hydrochloride
PrecautionsGlucagon will have little or no effect if patient is fasting or suffering from adrenal insufficiency, chronic hypoglycaemia or alcohol induced hypoglycaemia.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 102
10% GlucoseDrug Category: Glucose-Elevating Agents
Drug Name 10% Glucose
Indications/Doses Seizures 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Unconscious patient 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Gastroenteritis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Shock 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Suspected bacterial meningitis 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Poisoning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Drowning 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Head injury 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Abdominal pain 2.5 mL/kg IV/IO stat if BGL less than 3.5 mmol/L
Contraindications Avoid in dehydrated patients in a diabetic (hyperglycaemic) coma
Interactions Do not administer simultaneously with blood products via the same infusion line
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible
Precautions
May cause nausea, monitor fluid balance, electrolyte concentrations, and acid-base balance closely. Glucose administration may produce vitamin B-complex deficiency. Thrombophlebitis.
Fluid and/or solute overloading, serum electrolyte disturbance, over hydration, congested states, pulmonary oedema
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 103
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain
NSW Health PD2009_065 Infants and Children: Acute Management of Seizures
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
Australian Resuscitation Council, Guideline 12.4, Medications & Fluids in Paediatric Advanced Life Support; December 2010
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 104
Hydrocortisone sodium succinateDrug Category: Systemic Adrenal steroid hormones
Drug Name Hydrocortisone sodium succinate (Solu-Cortef)
Indications/DosesSevere and life-threatening asthma
4 mg/kg IV/IO stat
ContraindicationsKnown hypersensitivity, systemic fungal infections; premature infants; live attenuated vaccines.
Interactions
Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone. Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Decreases the efficiency of the following medications; Aspirin, Insulin, oral anti-diabetic medication, oral contraceptive pill
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible
Precautions Cirrhosis or hypothyroidism may enhance the effect of corticosteroids
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2012_014 Infants and Children – Acute Management of Asthma
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 105
Ipratropium Bromide Drug Category: Bronchodilator
Drug Name Ipratropium Bromide (Atrovent)
Indications/DosesSevere and life-threatening asthma
Child less than 20kg; 250 micrograms 3 x 20 minutely via nebuliser. Child greater than 20kg; 500 micrograms 3 x 20 minutely via nebuliser
Contraindications Documented hypersensitivity to ipratropium
Interactions
Drugs with anticholinergic properties may increase toxicity. Cardiovascular effects may increase with Monoamine Oxidase Inhibitors, tricyclic antidepressants and sympathomimetic agents. Disodium cromoglycate inhalation solutions containing benzalkonium chloride. Beta-Adrenergics and xanthine
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.
PrecautionsCaution in glaucoma (protect eyes if nebuliser in use), hyperthyroidism, diabetes mellitus, cardiovascular disorders and cystic fibrosis. May cause bronchoconstriction in some patients with hyper reactive airways
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2012_014 Infants and Children – Acute Management of Asthma
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 106
Midazolam Drug Category: Sedatives, hypnotics
Drug Name Midazolam hydrochloride
Indications/Doses Seizuresn 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once
only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once only).
Head injury (if seizures)n 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once
only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once only).
Suspected bacterial meningitis (if seizures)n 0.3 mg/kg buccal (to a maximum dose of 10mg) stat and repeat after 5 minutes if required (once
only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once only).
Poisoning (if seizures)n 0.3 mg/kg (to a maximum dose of 10mg) buccal stat and repeat after 5 minutes if required (once
only). n 0.15mg/kg IM/IV/IO stat (to a maximum of 5mg) and repeat after 5 minutes if required (once
only).
Contraindications Documented hypersensitivity; pre-existing hypotension
Interactions
The sedative effects of neuroleptic, tranquillizers, antidepressants, sleep inducing drugs, analgesics, anaesthetics, antipsychotics, anxiolytics, antiepileptic drugs and sedative antihistamines may be enhanced by the administration of midazolam. Pre medication, alcohol and barbiturates may increase the sedative effect of midazolam.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
PrecautionsRespiratory depression, apnoea, cardiovascular depression and cardiac arrest. Pharmacokinetics in children has not been established in children less than 8 years and may differ from adults.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2009_065 Infants and Children: Acute Management of Seizures
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 107
Morphine SulphateDrug Category: Analgesics
Drug Name Morphine sulphate.
Indications/Doses Recognition of a sick child 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Burns (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Head injury (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Abdominal pain (if pain score 4-10) 0.1 mg/kg IV/IO (repeat once in 10 minutes if necessary to a maximum dose of 10mg)
Contraindications Documented hypersensitivity; severe respiratory disease, coma.
Interactions Respiratory depressant and sedative effects may be additive toxicity in the presence of other medication.
Pregnancy
Category C
Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
PrecautionsCaution in hypotension, nausea, vomiting, supraventricular tachycardia; has vagolytic action and may increase ventricular response rate. Caution in patients with severe renal, hepatic dysfunction, may cause excessive sedation or coma.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 108
Naloxone Drug Category: Sedatives, hypnotics
Drug Name Naloxone
Indications/Doses Unconscious patient 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary
Poisoning 0.1mg/kg/dose (maximum 2 mg) IV, IO, IM, Sub Cutaneous, repeat as necessary
Contraindications Documented hypersensitivity.
Interactions Decreases analgesic effects of opioids. Effects of partial agonists eg buprenorphine, tramadol only partially reversed by naloxone
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage
Precautions
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
Royal Children’s Hospital Melbourne Paediatric Pharmacopoeia http://pharmacopoeia.hcn.com.au/?acc=36422<accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 109
OndansetronDrug Category: Antiemetics
Drug Name Ondansetron
Indications/DosesGastroenteritis
0.2 mg/kg oral stat (one dose only) (Maximum dose 8 mg)
Contraindications Hypersensitivity to any component of the preparation
Interactions May reduce the analgesic effect of tramadol. phenytoin, carbamazepine and rifampicin increase the oral clearance time and reduces the blood concentration of Ondansetron. Avoid the concomitant use of drugs that prolong the QT interval.
Pregnancy
Category B1
Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage.
Precautions Subacute intestinal obstruction, not recommended in breast feeding
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 110
Oxycodone Drug Category: Narcotic analgesic
Drug Name Oxycodone
Indications/Doses Recognition of a sick child
Oral Oxycodone 0.1 mg/kg (maximum 5 mg) stat
Burns
Oral Oxycodone 0.1 mg/kg (maximum 5 mg) statHead injuryOral Oxycodone 0.1 mg/kg (maximum 5 mg) stat
Abdominal pain
Oral Oxycodone 0.1 mg/kg (maximum 5 mg) stat
ContraindicationsKnown hypersensitivity to opioid analgesics. CNS depression. Respiratory Depression, raised intra cranial pressure, concomitant monoamine oxidase inhibitors. Children less than 1 year old.
Interactions CNS depressants. Monoamine oxidase inhibitors
Pregnancy
Category C
Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible.
Pregnancy Respiratory depression, hypotension; hypovolaemia; impaired renal or hepatic function
Precautions
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence; if patients do not respond to multiple doses of naloxone, consider alternative cause of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Be cautious of administration to neonates whose mothers are known or suspected to be addicted to opioids, as it may cause an abrupt and complete reversal of opioid effect and acute withdrawal syndrome
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 111
Paracetamol (oral) Drug Category: Analgesic and antipyretic
Drug Name Paracetamol (oral)
Indications/Doses Recognition of the sick childDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
BurnsDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Head injuryDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Abdominal painDose is recommended for patients of normal or average build; if not nil by mouth15mg/kg/dose 4th hourly to a maximum of 60mg/kg/day.
Single dose never to exceed 1gm and no more than 4gms in 24 hours.
Contraindications Documented hypersensitivity. Patient is nil orally
Interactions Anticoagulants; drugs affecting gastric emptying; hepatic enzyme inducers including alcohol, anticonvulsants
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsPrior to administration determine recent administration of any medicines containing Paracetamol. Caution in severe renal or hepatic dysfunction
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 112
Paracetamol (oral) continued
Drug Category: Analgesic and antipyretic
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department
NSW Health PD2009_009 Paracetamol Use
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 113
PrednisoloneDrug Category: Systemic corticosteroid
Drug Name Prednisolone
Indications/Doses Asthma
Mild 1 mg/kg oral stat-if prolonged episode or a history of severe asthma
Moderate 1 mg/kg oral stat
Severe 1 mg/kg oral stat-if tolerated orally
Croup 1 mg/kg oral stat-if tolerated orally and Dexamethasone unavailable
Contraindications Documented hypersensitivity to Prednisone, Tuberculosis, systemic fungal infection
Interactions Live vaccines (should not use); alcohol; antacids; antidiabetics; diuretics; hepatic enzyme
inducers eg phenytoin and rifampicin; cyclosporin; ketoconazole; anticoagulants.
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
Precautions Patients who are immunosuppressed, live vaccines
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW Health PD2012_056 Infants and Children: Acute Management of Asthma
NSW Health PD2010_053 Infants and Children: Acute Management of Croup
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 114
Salbutamol sulphate (Ventolin) Drug Category: Bronchodilator
Drug Name Salbutamol sulphate (Ventolin)
Indications/Doses
Anaphylactic reaction
Metered dose inhaler + spacer; n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze present
Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)
Asthma
Mild - Metered Dose Inhaler + spacer n Child less than 20kg 6 puffs of 100 microgram Metered Dose Inhaler + spacer stat n Child greater than 20kg 12 puffs of 100 microgram Metered Dose Inhaler + spacer stat
ModerateMetered Dose Inhaler + spacer n Child less than 20kg; 6 puffs of 100 micrograms Metered Dose Inhaler + spacer
repeat every 20 minutes n Child greater than 20kg; 12 puffs of 100 micrograms Metered Dose Inhaler + spacer
repeat every 20 minutes
Nebulisern Child less than 20kg; 2.5 mg nebule repeat every 20 minutes (if patients cannot inhale
adequately to use an MDI and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule repeat every 20 minutes (if patients cannot inhale
adequately to use an MDI and spacer or require oxygen therapy)
Severe/life-threateningContinuous nebulisern Load 4 mL of undiluted 0.5% Salbutamol Solution into nebuliser and
top up as required
Drowning n Child less than 20kg; 6 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze presentn Child greater than 20kg; 12 puffs of 100 microgram Metered Dose Inhaler + spacer
stat if wheeze present
Nebulisern Child less than 20kg; 2.5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or requires oxygen therapy)n Child greater than 20kg; 5 mg nebule stat (if patients cannot inhale adequately to use an MDI
and spacer or require oxygen therapy)
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 115
Salbutamol sulphate (Ventolin) continued
Drug Category: Bronchodilator
Drug Name Salbutamol sulphate (Ventolin)
Contraindications History of hypersensitivity; Can cause paradoxical bronchospasm; allergic reactions
Interactions May increase cardiovascular effects of other sympathomimetics
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsMay cause tachycardia, nausea and tremors. Caution in patients with co-existing cardiovascular disease. Hypokalaemia can occur with high dose particularly in combination with other potassium depleting medications.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health GL2012_003 Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 http://www0.health.nsw.gov.au/policies/gl/2012/GL2012_003.html <accessed 06/03/14>
NSW Health PD2012_014 Infants and Children – Acute Management of Asthma
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 116
0.9% Sodium ChlorideDrug Category: Intravenous Fluids
Drug Name 0.9% Sodium Chloride
Indications/Doses IV/IO Cannula Flush - 2mL Medication dilution - as per medication protocol. Indications/Doses For the following conditions:
Recognition of a sick child IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Anaphylactic reaction IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Seizures IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Unconscious patient IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Cardiorespiratory arrest - Advanced Life Support IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Shock IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Gastroenteritis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Suspected bacterial meningitis IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Poisoning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Snake/spider bite IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Burns IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Drowning IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Head injury IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 117
0.9% Sodium Chloride continued
Drug Category: Intravenous Fluids
Drug Name 0.9% Sodium Chloride
Indications/Doses continued
Abdominal pain IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged capillary refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Febrile neutropaenia CVAD/IV/IO 20 mL/kg bolus If shocked: tachycardic, bradycardic, hypotensive, prolonged cap refill or mottled skin, capillary refill greater than 2 seconds (centrally)
Contraindications
Interactions Amiodarone
Pregnancy
Category A
Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
PrecautionsCongestive cardiac failure, severe renal impairment, sodium retention. Do not use if the solution is not clear.
Modified from:
MIMS Online https://www.mimsonline.com.au <accessed 06/03/14>
Australian Medicines Handbook http://amh.hcn.com.au/ <accessed 06/03/14>
Australian Injectable Drugs Handbook, Fourth Edition http://aidh.hcn.com.au/index.php <accessed 06/03/14>
NSW Health PD2010_009 Infants and Children: Acute Management of Gastroenteritis
NSW Health PD2011_038 Recognition of a Sick Baby or Child in the Emergency Department
NSW Health PD2013_044 Infants and Children: Acute Management of Bacterial Meningitis
NSW Health PD2013_053 Infants and Children: Acute Management of Abdominal Pain
NSW Health PD2010_063 Infants and Children: Acute Management Fever
NSW Health PD2009_065 Infants and Children: Acute Management of Seizures
NSW Health PD2011_024 Infants and Children: Acute Management of Head Injury
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 118
Ideally the following equipment should be stored on a freely moving mobile trolley with IV pole
It is recommended that Paediatric contents are stored in a separate drawer
Essential Paediatric EquipmentBroselow™ Tape
Infant Scales
Note: The Paediatric requirements listed below are in addition to the minimum adult requirements as listed in the
NSW Rural Adult Emergency Clinical Guidelines (appendix 1) Please refer to the adult guidelines for rural and remote
emergency trolley – minimum requirements.
AirwayETT 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6mm uncuffed
LaryngoscopeSmall handle with batteries x 2
Blade – straight size 1, curved size 1 & 2
Oropharyngeal rigid sucker Small (paediatric size)
Oropharyngeal airway 000, 00, 1
Introducer Small and medium paediatric bougie or introducing stylet (6Fg, 10Fg)
Tape Zinc oxide (brown) 1 inch roll
Other Magills forceps infant (18cm) and child (20cm)
Breathing
Self-inflating resuscitation bags with reservoir bag, pressure relieving valve, and oxygen tubing
Preterm (240mL)
Paediatric (450mL)
Clear resuscitator masks Sizes 00, 0, 1, 2
Y Suction catheters Sizes 6Fg, 8Fg, 10Fg
Rural and Remote Emergency Trolley – Minimum Paediatric Requirements
APPENDIX 1
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 119
Circulation
Needleless T piece extension tubing
X 3 paediatric size
Indwelling urinary catheter 6Fg, 8Fg, 10Fg, 12Fg
Arm boards Paediatric
Adhesive tapes Brown tape ½ inch, or paediatric IV site dressing
Intraosseous Manual or battery operated insertion device with paediatric and adult size needles
OtherECG dots (Paediatric)
Defib pads x 2 packets (Paediatric)
NG tube (size 8Fg, 10Fg, 12Fg)
Paediatric Advanced Life Support algorithm
ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010
Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 120
Airway and breathingNasopharyngeal airway Sizes 6, 7
Cervical collar Laerdal stiffneck, Pedi-select collar, Baby ‘No-neck’
Oxygen mask (Hudson) Paediatric
Nasal prongs Infant, paediatric
Non – rebreather mask Paediatric
Stethoscope Paediatric
Pulse oximeter with pleth (waveform)
Sensors (probes): infant finger/ear/ finger/forehead sensor
Spacer and mask for metered dose inhaler
Paediatric size
Nebuliser Mask Paediatric
Circulation
Amethocaine 4% and/or EMLA gel
For cannulation
Tourniquet Paediatric friendly
Pathology tubes Paediatric tubes and blood culture bottles
Intravenous solutions 0.9% Sodium Chloride + 5.0% Glucose, 0.45% Sodium Chloride + 5.0% Glucose
Glucometer
DisabilityGlasgow Coma Scale Modified (paediatric)
Additional Recommended Paediatric Equipment
APPENDIX 2
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 121
Environment, Comfort & SafetyThermometer Axilla Probe, paediatric tympanic, flexible rectal probe (optional)
Heat source Overhead heater or other heat source (optional)
Distraction activities box
Oral use only medication syringes
1mL, 3mL, 5mL, 10mL
Cot / bed with rails in situ Bunny rugs, cot sheet & blankets
Infant formula Disposable bottle & teat, feeding cup
Gastrolyte, Hydrolyte or similar
Ice blocks and solution
Trial of oral fluids chart
Kitchen scales (1g increments)
To weigh nappies
Disposable nappies
ReferenceNSW Health PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric Medicine and Surgery, June 2010
Resuscitation Standards for Clinical Practice and Education Provision Australian Resuscitation Council, Australian Council of Critical Care Nurses http://www.resus.org.au/policy/documents/clinical_standards_for_resuscitation_march08.pdf <accessed 06/03/14>
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 122
The child’s oxygenation status should be assessed in a
well-lit room by assessing clinical signs and symptoms,
and recording baseline observations. Temporary exposure
of the child, including the head, thorax and abdomen is
an essential part of respiratory assessment.
Assessment of child presenting with rapid or laboured breathing.n Increased work of breathing [tracheal tug/costal or
sternal recession/ see-saw breathing]
Effort mostly on inspiration or expiration?
– inspiration-upper airway obstruction likely
– expiration-lower airway obstruction likely
n Causes of inspiratory obstruction
– croup, foreign body aspiration, bacterial tracheitis,
tonsillar abscess, epiglottitis and
diphtheria (rare in the immunised child in Australia)
n Causes of expiratory obstruction
– wheeze +/- crackles (asthma, bronchiolitis, lower
respiratory tract infection, anaphylaxis, foreign
body).
n Rapid breathing (without increased work of breathing)
– anxiety, fever, pain, pneumonia, severe anaemia
and metabolic acidosis, including starvation, sepsis,
diabetic ketoacidosis, and salbutamol overdose,
heart failure.
Management of the tachypnoeic or dyspnoeic child:n Hypoxia – treat with high flow inhaled O2. It should
be suspected particularly in the agitated, combative
or ‘naughty’ child (particularly if out of character), and
confirmed with oximetry or capillary blood gas (see below)
n Hypercapnoea may be increasingly recognised with
the use of end-tidal CO2 monitors, and treated with
continuous positive airways pressure, for example in
infants with a Neopuff®.
n Care should be taken to avoid over-extension or
flexion of the child’s neck to avoid increasing upper
airways obstruction. Often the best position for a
conscious child is sitting on a carer’s lap, to try to
minimise distress, and O2 consumption.
n Wheezing will often respond to salbutamol in the
child over the age of 12 months – see asthma
guideline for dosage. Bronchodilators are less likely
to be helpful before the first birthday, and may
occasionally make matters worse.
Monitoring oxygen levels and oxygen delivery n Oximetry probe of the correct size should be
positioned appropriately and baseline observations
recorded in room air.
n An oximetry reading greater than 94% in room air is
desirable.
n Oximetry readings less than 94% with or without
clinical signs and symptoms of respiratory distress or
hypoxia, indicate the need for supplementary oxygen
in the acutely ill child.
n Not all children with increased oxygen requirements
exhibit respiratory symptoms, eg the shocked child,
drug overdoses, seizures, trauma and dehydration.
n All nebulised medication should be administered via
wall or cylinder oxygen to maximise effectiveness,
irrespective of the child’s needs for continuous
supplementary oxygen between medications.
n When receiving oxygen therapy the child should be
continuously monitored by use of oximetry for 2 hours
initially. A minimum of hourly spot oximetry readings
should be attended in conjunction with hourly pulse,
respirations and assessment of respiratory status, ie
chest recession, tracheal tug, nasal flaring, arousal,
activity level and level of consciousness.
n Full explanation should be given to both the child
and carer regarding the importance of continuous
monitoring and observation.
n Any increase in oxygen demands or deterioration
in the child’s condition should be reported to the
Medical Officer immediately.
ReferenceHNE Health (2005) ‘Paediatric Oxygen Therapy’ Hunter
Emergency Services Policy, Hunter Area Emergency
Guidelines Committee.
Mackway-Jones, K. Molyneuz, E., Phillips, B. & Wieteska
[Eds]. (2005) Advanced Paediatric Life Support - The
practical approach 4th edn. BMJ Books, London
Aehlert, B. (2007) Mosbsy comprehensive pediatric
emergency care (2nd. ed.) Elsevier: St Louis. Chapter 4
Respiatory Distress and Failure p 87-142 & Chapter 5
Respiratory Interventions p 143-217
Paediatric Respiratory Assessment
APPENDIX 3
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 123
The AVPU scale is a useful method of rapidly measuring
the level of consciousness.
A ALERTV responds to VOICEP responds to PAINU UNRESPONSIVE
If there are any concerns regarding the child’s level of
consciousness the modified Glasgow Coma Scale should
be used.
MODIFIED GLASGOW COMA SCALE
Best Eye Opening ResponseSpontaneous 4
To voice 3
To pain 2
Nil 1
Best Verbal ResponseAppropriate conversation Infant-appropriate words/social smile/fixes and follows
5
Confused but recognizable speech Infant – cries but is consolable
4
Some words, inappropriate mumble Infant – Persistently irritable
3
Groans Infant – Restless, agitated
2
Nil 1
Best Motor ResponseObeys Commands 6
Localises pain 5
Withdraws to pain 4
Flexor/decorticate response to pain 3
Extensor/decerebrate response to pain 2
Flaccid paralysis 1
Total = Eye opening + Best verbal response + Best motor response = 3 - 15
A GCS Score less than < 9 requires urgent airway management.
A GCS Score less than <14 requires immediate medical attention.
ReferencesNSW Health PD2011_024 Infants and Children: Acute
Management of Head Injury.
Mackway-Jones, K. Molyneuz, E., Phillips, B. & Wieteska
[Eds]. (2005) Advanced Paediatric Life Support –
The practical approach 4th edn. BMJ Books, London.
AVPU and the Modified Paediatric Glasgow Coma Scale
APPENDIX 4
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 124
This is a systematic approach used for patient assessment
and treatment when the patient has life-threatening
conditions or injuries. The Primary/Secondary Survey
emphasises the importance of prioritising and instigating
the correct sequence of care.
Noten Infants and young children are prone to hypothermia.
Although it is important to expose children for
assessment, it is necessary to provide external heating
like warm blankets/towels or overhead heating
during this procedure.
n Hypothermia in the infant and young child can hasten
or lead to more serious illness.
The Primary Survey consists of a rapid patient
assessment and treatment of any immediately life-
threatening conditions.
This will involve simultaneous assessment and treatment
of the following:
n Airway with cervical spine controln Breathing and ventilationn Circulation and haemorrhage control n Disability – neurologicaln Exposure (undress the patient).
Secondary Survey is a systematic assessment of
the patient from head to toe, so that each body
system is reviewed. It includes patient history
and commencement of relevant investigations.
Using a systematic approach:
n Head and Facen Neckn Chestn Abdomenn Pelvis and Genitalian Upper and Lower Limbsn Backn Vital signsn History – Including mechanism of injury past
and present medical history and relevant family history
n Investigationsn Documentation.
Throughout the Secondary Survey the patient requires
continuous monitoring and assessment, if there is any
deterioration, the Primary Survey should be repeated.
ReferenceSkinner. D, Driscoll. P, Earlam. R. (2000). ABC of Major
Trauma. BMJ. 3rd Edition. Cambridge University Press.
Primary and Secondary Survey
APPENDIX 5
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 125
ReferenceNSW Health 2013, GL2014_005 Snake and Spiderbite Clinical Management Guidelines Third Edition.
Patient surname Date of bite Time of bite
Forename Date of birth Type of snake
MRN number Number of bites
DateTimeTime after biteGeneral
Pulse rateBlood pressureTemperature
Specific
Regional lymph node tendernessLocal bite site painBite site swellingHeadacheNauseaVomitingAbdominal pain
Paralytic Signs
PtosisOpthalmoplegiaFixed dilated pupilsDysarthriaDysphalgiaTongue protrusionLimb weaknessRespiratory weaknessPeak flow rate
Myolytic Signs
Muscle painMyoglobinuria
Coagulopathy Signs
Persistant blood oozeHaematuriaActive bleeding
Renal
Urine outputLaboratory Key Tests
INR/prothrombin time aPTTFibrinogenXDP/FDPPlatelet countCKCreatinineUreaK+
Antivenom
Type/amount/timeReaction
Snakebite Observation Chart
APPENDIX 6
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 126
Effective pain management in the paediatric patient
begins with an accurate, developmentally appropriate
assessment of pain. This includes parent and/or child self
reports (eg pain ladder, faces scales) and the assessment
of behaviour eg crying, whimpering, lack of interest
in play and surroundings, irritability, general activity
and physical parameters eg tachycardia, tachypnoea,
sweating.
It is desirable that infants and children are not separated
from their parents or primary care giver during clinical
assessment or whilst undergoing invasive procedures
such as IV cannulation, NG tube insertion.
Remember to incorporate supportive and distractive
techniques into all pain management strategies.
These include utilising games, puzzles, familiar toys,
music, video/TV viewing, reading, cuddling, support from
parents and pacifiers (dummies, security object etc).
The following list indicates behaviours that would
prompt you to undertake a more formal pain assessment.
n Limited movement
n Distressed/irritable/grimacing
n Obvious deformity
n Guarding or posturing
n Inconsolable
The age and development of the infant or child will
influence how they might behave when in pain. The
following table provides a guide to age related pain
behaviours.
Age Behaviours
Infants
Young infant – rigid, thrashing, reflex withdrawalLoud cryFacial expressionKnees drawn to chestIrritableStimuli/responseOlder infant-physical resistance
Young Child
Scream/cryThrashingUncooperative (need restraining)Cling to parentSeek comfortRestless/irritable
School Age
As previous plusStalling behaviors “wait until”, “in a minute”Muscle rigidityClenched fistGritted teethClosed eyesFrown
Adolescent
Less vocal protestLess motor activityMore verbal communication –“it hurts”Increased muscle tensionBody control
Paediatric Pain Assessment
APPENDIX 7
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 127
NoteRepeated pain assessment is essential.
Pain Assessment Tools
Infant - 7 years: FLACC Behavioural Assessment Tool (report of observer).
Scoring: Add the score for each category to give a total pain score out of 10. Document on appropriate chart.
Reference: Hunter New England Four Hourly Graphic Chart HNEMR11
Children > 7 yo: Visual Analogue Scale (VAS) or Verbal Rating Scale (VRS) (report of patient).
Document score on appropriate chart.
CATEGORIESSCORING
0 1 2
Face No particular expression or smile.
Occasional grimace or frown, withdrawn, disinterested.
Frequent to constant quivering chin, clenched jaw.
Legs Normal position or relaxed. Uneasy, restless, tense. Kicking, or legs drawn up.
Activity Lying quietly, normal position, moves easily.
Squirming, shifting back and forth, tense. Arched, rigid or jerking.
Cry No cry (asleep or awake).
Moans or whimpers, occasional complaint.
Crying steadily, screams or sobs, frequent complaints.
Consolability Content, relaxed.Reassured by occasional touching, hugging or being talked to, distractible.
Difficult to console or comfort.
Reference: (Merkel et al. 1997).
Instructions to the child: “These faces show how much something can hurt. From no pain (indicate face on the left),
the faces show more and more pain, to the face that shows very much pain (indicate the face on the right). Point to the
face that shows how much you hurt”. Scoring: Score the selected face 0, 2, 4, 6, 8 or 10 counting from left to right.
The scale is intended to measure how patients feel inside, not how their face looks. Document on appropriate chart.
Hicks et al. pain 2001
Children > 3 yo: Faces Pain Scale – Revised (report of patient)
NO PAIN WORST PAINMODERATE PAIN
0 1 2 3 4 5 6 7 8 9 10
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 128
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
page 14 of 21
NSW Severe Burn Injury Service Burn Transfer Flow Chart Medical Retrieval Referral Minor Burns
Meets Medical Retrieval • Intubated patients • Head and neck burns • Burns>10% in children or >20% in
adults • Burns with associated inhalation • Burns with significant co-morbidities
e.g. trauma • Electrical/chemical injury • Significant pre-existing medical disorder • Circumferential to limbs or chest
compromising circulation or respiration
Needs referral but not medical retrieval • Burns >5% children or >10% adults• Burns to hands, feet, face,
genitalia, perineum and major joints• Burns with a pre-existing medical
condition eg diabetes • Children with suspected non-
accidental injury & adults with assault, self inflicted injury
• Pregnancy ( 2nd 3rd trimester RNSH)
• Spinal cord injury -RNSH • Extremes of ages
Minor burns are treated in consultation with the referring doctor as an outpatient; either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment.
Contact NETS for children AMRS Adults up to16th birthday 1800 65 0004 1300 36 2500
The Children’s Hospital at Westmead Catchment Area: All children’s referrals to the age of 16 in all areas of NSW
Concord Repatriation General Hospital Catchment Area: South Eastern Sydney/Illawarra, Sydney West, Sydney South West, Greater Southern٭, Greater Western٭, ACT
Catchment Area: North Sydney/Central Coast, Hunter/New England, North Coast٭ ٭refer to Burns Units in adjoining states
Contact Burn Ambulatory CareCHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h)
Set up conference call with receiving ICU/Burn Unit, facilitates communication with primary referral site
CHW ICU 9845 1171 CRGH ICU 9767 6404 RNSH ICU 9926 8640
CHW: Surgical Registrar on-call notified Tel. 9845 0000 then page Surgical Registrar CRGH: Burns Registrar on-call notified Tel 9767 5000 then page Burns Registrar RNSH: Burns Registrar on-call notified Tel 9926 7111 then page Burns Registrar
Not referred to service
AMRS/NETS will coordinate transfer between primary hospital and the receiving hospital
The on call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receiving the patient. The referrer will make the ambulance booking.
Referred to service
Any issues or problems with these processes or if further advice is required, The NSW Severe Burn Injury Service Manager can be contacted on 02 9926 5641.
Royal North Shore HospitalCatchment Area: NorthSydney/Central Coast, Hunter/NewEngland, North Coast
Hospitals near state border areas mayrefer to Burns Units in adjoining states
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
Burn Injury Referral/Retrieval Check List
APPENDIX 8
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 129
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
page 15 of 21
Appendix 1: Burn Patient Emergency Assessment & Management Chart
To be used for patients requiring transfer to a specialised burn unit.
Place patient label here or: MRN: Name: D.O.B. Sex: AMO: Ward:
Presentation Date: ____________ Time: ___________ Trauma Call: � YES � NO
Burn Date: _____________ Burn Time: ___________ Triage Category: ___________
Weight (kgs): _____________ Doctor: _______________________________________
Burn Mechanism: ________________________________________________________________ ________________________________________________________________________________ First Aid given (as defined below): � NO � YES Specify ___________________________
FIRST AID • At least 20 mins cold running water (8 - 25°C). Effective up to 3 hours post injury.• Protect against hypothermia, keep rest of body warm. Cease cooling if body temp <35°C
PRIMARY SURVEY Airway � Normal � Neck/facial burns with swelling � Burn in confined space � Intubated � Hoarse Voice / Stridor / Cough / Carbonaceous material – mouth / nose / sputum C Spine � Normal � At Risk � Immobilised Breathing RR ___ Air Entry ______ O2 sats ___ FiO2 ___ Effort - normal/shallow/increased Burn circumferential around chest / torso / neck? � Yes � No Circulation HR _____________ BP ________ / _________ Central capillary refill � 1-2 seconds � > 2 seconds � Absent Any circumferential burns? � No � Yes, specify area/s _____________________ Peripheral capillary refill � 1-2 seconds � > 2 seconds � Absent Disability Level of consciousness (AVPU): __________ Pupils: (L) ___ mm (R) ___ mm AVPU = A – Alert, V - Response to Vocal stimuli, P - Responds to Painful stimuli, U - UnresponsiveEnvironment Patient Temp. ____°C @ _____________ (time/date) Temp route ___________ Remove clothing and jewellery Keep unburnt areas warm Warm IV fluids � No � Yes �N/A Warm blankets � No � Yes � N/AAssess % Total Body Surface Area (TBSA) burnt using Rule of Nines (see page 2) TBSA body chart completed? � No � Yes By whom? _______________
Fluid Resuscitation (see page 3 for specific fluid calculations) � Not required Large bore IVCs (2 for >20%, 1 for >10%) or CVL inserted? � No � Yes Bloods taken: � FBC � EUC � BSL � Coags � COHb � Drug screen IDC Inserted? (if % TBSA > 10% or perineum) � No � Yes Nasogastric tube inserted? (if % TBSA > 15%) � No � Yes Co-existing injuries? � Yes � Possible (eg blast / electrical injury) � No Specify ________________________________________________________________________
PAIN MANAGEMENT Morphine is the drug of choice for acute pain following burns. If allergic use appropriate alternative. • Adults Stat IV morphine 2mg, repeat every 5mins as required Max. 0.2mg/kg• Children Stat IV morphine 0.1mg/kg, repeat every 15mins as required Max. 0.3mg/kg• Reassess every 5 minutes and discuss with appropriate medical staff if analgesia insufficient • Minor burn Oral analgesia (eg paracetamol +/- codeine / oxycodone, etc) may be adequate Analgesia given prior to presentation: � No � Yes Specify _____________________________ Pain Score ____________ Time ____ (use age appropriate pain rating scale) Analgesia given ______________ Dose _______ Time _______ Effective � No � Yes
IMMUNISATION Immunisations up to date? � No � Yes Specify __________________________________ Tetanus status: � Primary course given � Give Immunoglobulin if < 3 doses � Last dose of booster _________ � Give booster if last booster > 5yrs ago
Burn Patient Emergency Assessment & Management Chart
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 130
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
ASSESSMENT OF % TOTAL BODY SURFACE AREA (TBSA) AND BURN DISTRIBUTION
Total Body Surface Area Rule of Nines Palmar
Palm + fingers = 1%
BURN DISTRIBUTION (shade affected areas on diagram below)
PaediatricFor every year of life after 12
months take 1% from the head and add ½% to each leg,
until the age of 10 years when adult proportions
Shade affected area
Total % TBSA = ______
NB Faint erythema not included in % TBSAassessment
NB Difficult to accurately assess burn depth within the first 24 - 48 hrs post injury
(Patient’s hand)
Adult
Assessment of % Total Body Surface Area (TBSA) and Burn Distribution
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 131
GuidelineTitle: Burn Transfer Guidelines – NSW Severe Burn Injury Service – Second Edition
page 17 of 21
RESUSCITATION FLUIDS (if > 10% TBSA for children, >15% for adults)
Weight ________ kg Modified Parkland Formula = 3-4 mls x weight (kg) x % TBSA burn
to be given as Hartmann’s solution in 24hrs following the injury (see Transfer Guidelines) 3-4 mls x ________kg x _________% TBSA = total fluids for 1st 24hrs
* NB This is a guide only - Titrate fluids to urine output*Total resuscitation fluids in 24hrs _______ mls
Start time ______ Finish time _______50% Replacement in 1st 8hrs following injury _______ mls Total Fluid given prior to admission _______ mls Subtract Fluid already given = fluid to be given to complete 1st 8hrs _______ mls Hourly rate for replacement (within 1st 8 hrs) mls/hr
Start time ______ Finish time _______ Remaining 50% of Replacement in next 16hrs _______ mls Hourly rate for replacement (in subsequent 16 hrs) _______ mls/hr
Start time _______ Finish time ______ Maintenance fluids (for children < 30kgs only) _______ mls/hr
MAINTENANCE FLUIDS (Not applicable for adults) Children < 30kg require maintenance fluids (N/2 Saline + 2.5% Dextrose) in addition to resus. fluids.
Up to 10kg 100ml/kg/day 10-20kg 1000mls plus 50ml/kg/day (for each kg >10kg and <20kg)20-30kg 1500mls plus 20ml/kg/day(for each kg > 20kg)
URINE OUTPUT • Children 1ml/kg/hr (range 0.5 – 2ml/kg/hr) • Adults 0.5 – 1 ml/kg/hr • 2ml/kg/hr required for pigmented urine such as myoglobinuria / haemoglobinuria
REFERRAL CRITERIA Refer to Transfer Guidelines (“Referral” meaning contact with not necessarily transfer to Burn Unit)
• Partial/full thickness burns in children >5% TBSA, in adults >10% TBSA. • Any priority areas are involved, i.e. face/neck, hands, feet, perineum, genitalia and major joints. • Caused by chemical or electricity, including lightning. • Any circumferential burn. • Burns with concomitant trauma or pre-existing medical condition. • Burns with associated inhalation injury. • Suspected non-accidental injury. • Pregnancy with cutaneous burns NB All paediatric burns (<16 yrs) fitting any of the above criteria need referral to The Children’s Hospital at Westmead (CHW). Adult burns fitting above criteria need referral to the adult unit at Royal North Shore Hospital (RNSH) or Concord Repatriation General Hospital (CRGH) (dependent on area health service intake area). For contact details see Transfer Guidelines.
DRESSING For transfer to specialist unit within 8 hrs apply cling film to burnt areas (Vaseline gauze/white paraffin for face). Do not wrap circumferentially. For delayed transfer > 8hrs apply antimicrobial dressing such as Vaseline gauze (eg Bactigras) or silver dressing, after discussion with burn unit. For burns not requiring transfer to specialist unit • give pre med analgesia 30mins prior to procedure (eg paracetamol +/ oxycodone, etc) • clean wound with chlorhexidine 0.1%, saline or clean water • apply appropriate dressing such as silver dressing or Vaseline gauze (see Minor Burn Management). Contact Burn
Unit for advice if required. • make follow-up appointment and advise on care and analgesia for home usage and pre-dressing.
Reference NSW Health. 2008. Burns Transfer Guidelines – NSW Severe Burns Injury service. 2nd edn. (GL2008_012).
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 132
LOW RISK INTERMEDIATE RISKHIGH RISK *CHALICE criteria (any feature)
HISTORY
Witnessed loss of consciousness nil less than 5 minutes greater than 5 minutes
Anterograde or retrograde
amnesianil possible greater than 5 minutes
Behaviour normalmild agitation or
altered behaviourabnormal drowsiness
Episode of vomiting
without other causenil or 1 2 or persistent nausea 3 or more
Seizure in non-epileptic patient nil impact only yes
NAI suspected no no yes
Headache nil persistent persistent
Co morbidities nil present present
Age greater than 1 year less than 1 year any
MECHANISM
Motor Vehicle Accident (MVA)
(pedestrian, cyclist or occupant)low speed less than 60 km/ph greater than 60 km/ph
Fall less than 1 metre 1-3 metres greater than 3 metres
Other low impactmoderate impact
or unclearhigh speed projectile or object
EXAMINATION
GCS 15 fluctuating14-15less than 14 or
less than 15 if under 1 year old
Focal neurological abnormality nil nil present
Injury *high risk features (see below)
High risk injury:
a) penetrating injury, or suspected depressed skull fracture or base of skull fracture.
b) scalp bruise, swelling or laceration greater than 5 cm, or tense fontanelle in infants less than 1 year of age.
*High risk adapted from the Archives of Disease in Childhood 2006, children’s head injury algorithm for the prediction of important clinical
events (CHALICE) study group, Derivation of the children’s head injury algorithm for rule for head injury in children the prediction of important
clinical events.
Head Injury Risk Categories
APPENDIX 9
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 133
Note: Children less than 1 year
n require greater vigilance due to difficulty in clinical
assessment and greater risk of abusive head injury
(Non accidental injury)
n a high index of suspicion for intracranial injury must
exist for these patients, if no other intermediate risk
factors present may be managed as low risk after
consultation with paediatric experts.
Inflicted head injury n If inflicted head injury is suspected consult
with paediatric referral hospital to discuss
the indicators of the case.
n If inflicted head injury is agreed child
should be transferred to a paediatric
tertiary referral centre
n Notify Department of Community Services.
MANAGEMENTLow risk n may be discharged after medical review if have
responsible carers
n must be able to return easily to the hospital in case
of deterioration.
Intermediate risk n admission and observation required for 4-6 hours
post injury
n GCS must be sustained at 15 for 2 hours
n CT indicated if acute deterioration or persisting
symptoms at 6 hours post injury
n may be discharged at conclusion of observation
period if GCS 15, asymptomatic child has responsible
carers and a normal CT (if performed)
n children who fail these categories should be
discussed with a paediatric expert or neurosurgical
unit.
High risk n urgent CT
n transfer/retrieval
n *if unable to be performed should have observation
for a minimum period of 24 hours.
Severe head injury- GCS less than 9
n trauma call +/- retrieval to nearest paediatric
referral centre.
NoteGiven the issues of distance and dislocation for families
if a child requires transfer to a larger centre, the benefits
of a CT scan have to be weighed against the risk of
delay of diagnosis resulting from an “observation only”
policy. All high risk patient who cannot have immediate
CT scanning should at a minimum, have prolonged
observation in hospital for at least 24 hours and until
clinically improved.
IDENTIFICATION OF ACUTE DETERIORATIONn a drop of one point in the GCS for at least 30
minutes (greater weight should be given to a drop in
the motor score of the GCS)
n a drop of greater than two points in the GCS
regardless of duration or GCS sub-scale
n development of severe or increasing headache or
persistent vomiting
n development of agitation or abnormal behaviour
n clinical signs suggestive of seizure activity
n clinical signs consistent with coning or unilateral/
bilateral pupillary deterioration
– Cushing’s reflex: hypotension, bradycardia and
irregular respirations
– extensor posturing or hemiparesis
– pupillary signs: sluggish reaction or unilateral/
bilateral pupil dilation
Note: The younger the child, the more non-specific the clinical
signs of elevated intracranial pressure.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 134
ReferenceNSW Health PD2011_024 Infants and Children: Acute
Management of Head Injury.
Dunning, J., Patrick Daly, J., Lomas, J-P., Lecky, F.,
Batchelor, J., Mackway-Jones, K. Derivation of the
children’s head injury algorithm for the prediction of
important clinical events decision rule for head injury in
children. Archives of Disease in Childhood 2006;91:885-
891. http://adc.bmj.com/cgi/content/full/91/11/885
<accessed 13.03.14>.
Minor head injury in infants and children,
http://www.uptodate.com/patients/content/topic.do?
topicKey=~vPPvq9tDRC2EMW&selectedTitle=26~143&
source=sear <accessed 13/03/14>.
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 135
Guideline for emergency department documentation
TRIAGE DOCUMENTATION STANDARD
1. Date and time of assessment
2. Name of triage officer
3. Chief presenting problem(s)
4. Limited, relevant history
5. Relevant assessment findings
6. Initial triage category allocated
7. Re-triage category with time and reason (if applicable)
8. Assessment and treatment area allocated
9. Any diagnostic, first aid or treatment measures initiated
(Australasian College for Emergency Medicine – ATS Guidelines Revised Nov 13)
Guideline for Emergency Department Documentation
APPENDIX 10
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 136
PRIMARY SURVEY DOCUMENTATION
A – Airway (& Cervical-Spine)
Patency, airway noises, mechanism of injury (spinal, head, inhalation injury) airway adjuncts (oro/nasopharyngeal/ LMA /ETT)
B – Breathing Respiratory rate, rhythm and depth, work of breathing, oxygen delivery device and amount
C – Circulation Skin colour, warmth and diaphoresis, capillary refill, pulses, overt bleeding, IV cannula (position and size) & fluids, (commence a fluid balance chart if fluids are administered)
D – Disability (neurological)
– Discomfort (pain assessment)
A – alertV – responds to voiceP – responds to painful stimuliU – unresponsive
Pupils size & reaction
(PEARL)
Pain assessmentand score
+ BGL
E – Exposure & Environment
Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure)
HISTORY(source – the patient, care giver or Ambulance Officer)
M – mechanism of injury / illness I – injuries sustained / illness progression S – signs & symptoms T – treatment (pre presentation) / transport
ONGOING ASSESSMENTTriage category 1- 3Record vital signs at time of assessment and frequency according to patient clinical presentations
Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)
Triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patient’s clinical presentation
Triage category 5 Record vital signs at time of assessment and relevant to presentation
Documented Observations – respiratory rate, oxygen saturations (SpO2)– oxygen device, and litres /minute – pulse, blood pressure, temperature– level of consciousness – GCS & pupils– blood glucose level (BGL)– pain score (0-10) and assessment – ECG – cardiac rhythm (if monitored)– neurovascular observations (if relevant)– weight (if relevant)– any investigations commenced /completed & outcome
A – allergiesM – medications (prescription, over the counter, herbal) P – past medical / surgical history L – last meal / last menstrual period / last immunisation E – events leading up to presentation
PLAN What plan has been put in place for this patient?
Document in a concise and clear manner: -– procedures, interventions, outcome & evaluation chronologically– standing orders or guidelines if commenced– notification – who has been told– comply with legal reporting responsibilities
EVALUATION Reassess patient and document outcomes
DISCHARGE – Time of departure– Destination– Referrals
• Document discharge information including any instructions or education given to the patient or family
• If patient not prepared to wait to be seen – document advice given to the patient or family
Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (ie alcohol/other drug use, smoking, skin integrity and falls screening)
NSW HEALTH 2014 Rural Paediatric Emergency Clinical Guidelines – 2nd Edition PAGE 137
Evidence indicates that a decrease in respiratory
rate is a late and unreliable indicator of respiratory
depression following opioid administration. Sedation
has been found to be a reliable early clinical indicator
of respiratory depression and should be monitored
following opioid administration using a sedation score.
Sedation Score
Behaviours
0 None
1 Mild, occasionally drowsy, easy to rouse
2 Moderate, constantly or
frequently drowsy easy to rouse
3 Severe, somnolent,
difficult to rouse
4 Normal sleep
The patient is scored according to the scale above.
The aim is to keep the sedation score below 2 regardless
of the route of opioid administration. A sedation score of
2 means that the patient is constantly drowsy or groggy
but still easy to rouse – eg they wake up easily but
cannot stay awake during conversation.
ReferenceNational Health and Medical Research Council,
1999, Acute pain management: scientific evidence,
Commonwealth of Australia, Canberra
Sedation Score
APPENDIX 11
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